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California State Prison Corcoran Medical Inspection OIG Report - April 2021

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Roy W. Wesley , Inspector General

OIG

Bryan B. Beyer, Chief Deputy Inspector General

OFFICE of the
INSPECTOR GENERAL

Independent Prison Oversight

April 2021

Cycle 6

Medical Inspection
Report
California State Prison
Corcoran

Electronic copies of reports published by the Office of the Inspector General
are available free in portable document format (PDF) on our website.
We also offer an online subscription service.
For information on how to subscribe,
visit www.oig.ca.gov.
For questions concerning the contents of this report,
please contact Shaun Spillane, Public Information Officer,
at 916-255-1131.

Return to Contents

California State Prison, Corcoran

iii

Contents
Introduction

1

Summary

3

Overall Rating: Inadequate
Medical Inspection Results

3
7

Deficiencies Identified During Case Review

7

Case Review Results

7

Compliance Testing Results

8

Population-Based Metrics

9

HEDIS Results

9

Recommendations

11

Indicators

15

Access to Care

15

Diagnostic Services

21

Emergency Services

25

Health Information Management

29

Health Care Environment

34

Transfers

42

Medication Management

48

Preventive Services

56

Nursing Performance

57

Provider Performance

62

Specialized Medical Housing

67

Specialty Services

71

Administrative Operations

77

Appendix A: Methodology

79

Case Reviews

80

Compliance Testing

83

Indicator Ratings and the Overall Medical Quality Rating

84

Appendix B: Case Review Data

85

Appendix C: Compliance Sampling Methodology

88

California Correctional Health Care Services’ Response

95

Report Issued: April 2021

Office of the Inspector General, State of California

Return to Contents

iv

Cycle 6 Medical Inspection Report

Illustrations
Tables
1. COR Summary Table
2. COR Policy Compliance Scores
3. COR Master Registry Data as of February 2020
4. COR Health Care Staffing Resources as of February 2020
5. COR Results Compared With State HEDIS Scores
6. Access to Care
7. Other Tests Related to Access to Care
8. Diagnostic Services
9. Health Information Management
10. Other Tests Related to Health Information Management
11. Health Care Environment
12. Transfers
13. Other Tests Related to Transfers
14. Medication Management
15. Other Tests Related to Medication Management
16. Preventive Services
17. Specialized Medical Housing
18. Specialty Services
19. Other Tests Related to Specialty Services
20. Administrative Operations

3
4
5
6
10
19
20
24
32
33
41
46
47
54
55
56
70
75
76
78

A–1.
B–1.
B–2.
B–3.
B–4.

80
85
86
87
87

Case Review Definitions
Case Review Sample Sets
Case Review Chronic Care Diagnoses
Case Review Events by Program
Case Review Sample Summary

Figures
A–1. Inspection Indicator Review Distribution for COR
A–2. Case Review Testing
A–3. Compliance Sampling Methodology

80
82
83

Photographs
1. Outdoor Waiting Area
2. Indoor Waiting Area
3. Individual Waiting Module
4. Residual Water Damage (view 1)
5. Residual Water Damage (view 2)
6. Expired Medical Supply
7. Expired Medical Supply
8. Expired Medical Supply
9. Staff Members’ Personal Items and Food Stored With Medical Supplies
10. Expired Lubricating Jelly
11. Expired Medical Supplies
12. Expired Medical Supplies
13. Blood on the Gurney Mattress

34
35
35
36
36
36
37
37
38
38
39
39
40

Cover: Rod of Asclepius courtesy of Thomas Shafee

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

1

Introduction
Pursuant to California Penal Code section 6126 et seq., the Office of
the Inspector General (OIG) is responsible for periodically reviewing
and reporting on the delivery of the ongoing medical care provided to
incarcerated persons1 in the California Department of Corrections and
Rehabilitation (the department).2
In Cycle 6, the OIG continues to apply the same assessment
methodologies used in Cycle 5, including clinical case review and
compliance testing. These methods provide an accurate assessment of
how the institution’s health care systems function regarding patients
with the highest medical risk who tend to access services at the highest
rate. This information helps to assess the performance of the institution
in providing sustainable, adequate care.3
We continue to review institutional care using 15 indicators, as in prior
cycles. Using each of these indicators, our compliance inspectors collect
data in answer to compliance- and performance-related questions
as established in the medical inspection tool (MIT).4 We determine a
total compliance score for each applicable indicator and consider the
MIT scores in the overall conclusion of the institution’s performance. In
addition, our clinicians complete document reviews of individual cases
and also perform on-site inspections, which include interviews with staff.
In reviewing the cases, our clinicians examine whether providers used
sound medical judgment in the course of caring for a patient. In the
event we find errors, we determine whether such errors were clinically
significant or led to a significantly increased risk of harm to the patient.5
At the same time, our clinicians examine whether the institution’s
medical system mitigated the error. The OIG rates the indicators as
proficient, adequate, or inadequate.

1. In this report, we use the terms patient and patients to refer to incarcerated persons.
2. The OIG’s medical inspections are not designed to resolve questions about the
constitutionality of care, and the OIG explicitly makes no determination regarding the
constitutionality of care the department provides to its population.
3. In addition to our own compliance testing and case reviews, the OIG continues to
offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for
comparison purposes.
4. The department regularly updates its policies. The OIG updates our policy-compliance
testing to reflect the department’s updates and changes.
5. If we learn of a patient needing immediate care, we notify the institution’s chief
executive officer.

Report Issued: April 2021

Office of the Inspector General, State of California

Return to Contents

2

Cycle 6 Medical Inspection Report

The OIG has adjusted Cycle 6 reporting in two ways. First, commencing
with this reporting period, we interpret compliance and case review
results together, providing a more holistic assessment of the care; and,
second, we consider whether institutional medical processes lead to
identifying and correcting provider or system errors. The review assesses
the institution’s medical care on both system and provider levels.
As we did during Cycle 5, our office is continuing to inspect both those
institutions remaining under federal receivership and those delegated
back to the department. There is no difference in the standards used for
assessing a delegated institution versus an institution not yet delegated.
At the time of the Cycle 6 inspection of California State Prison, Corcoran
(COR), the receiver had delegated this institution back to the department.
We completed our sixth inspection of COR and herein present our
assessment of the health care provided at COR during the inspection
period between August 2019 and January 2020.6 Notably, our report
of COR was not impacted by the novel coronavirus disease pandemic
(COVID-19). The data we obtained for COR predate COVID-19, so
neither case review nor compliance testing were affected. Similarly, the
on-site regional nurse review was not impacted by COVID-19. However,
during our on-site case review inspection, COR had patients who had tested
positive for the virus. The inspection was otherwise completed with no
further adjustments.
California State Prison, Corcoran, is located in the city of Corcoran in
Kings County. As of January 2020, the institution housed more than
2,900 incarcerated persons. COR operates multiple clinics, including
a specialty clinic, where staff members handle nonurgent requests
for medical services; a receiving and release clinic (R&R), where staff
conduct screenings; a triage and treatment area (TTA) for patients
requiring urgent or emergency care; a correctional treatment center
(CTC) to house patients requiring inpatient health services; and an
outpatient housing unit (OHU) to treat patients who require assistance
with activities of daily living, but who do not require a higher level of
inpatient care. California Correctional Health Care Services (CCHCS)
has designated COR as a basic care institution. Basic institutions are
located in rural areas, away from tertiary care centers and specialty care
providers whose services would likely be used frequently by higherrisk patients. Basic institutions have the capability to provide limited
specialty medical services and consultation for a patient population that
is generally healthy.

6. Samples are obtained per case review methodology shared with stakeholders in prior
cycles. The case reviews include death reviews that occurred between April 2019 and
February 2020, death reviews between February 2019 and January 2020, hospitalization
reviews that occurred between July 2019 and February 2020, registered nurse sick call
reviews that occurred between August 2019 and February 2020, and CTC reviews that
occurred between January 2019 and December 2019.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

3

Summary
We completed the Cycle 6 inspection of California State
Prison, Corcoran (COR), in July 2020. OIG inspectors
monitored the institution’s delivery of medical care that
occurred between August 2019 and January 2020.

Overall
Rating

Inadequate

The OIG rated the overall quality of health care at COR
as inadequate. We list the individual indicators and
ratings applicable for this institution in Table 1 below.

Table 1. COR Summary Table

Ratings
Proficient

Adequate

Inadequate

Overall

Change
Since
Cycle 5 *

N/A

N/A

N/A

N/A

Cycle 6 Ratings
Health Care Indicators

Case Review

Compliance

Access to Care
Diagnostic Services
Emergency Services

N/A

Health Information Management
Health Care Environment

N/A

Transfers
Medication Management
Prenatal and Postpartum Care

N/A

Preventive Services

N/A

N/A

Nursing Performance

N/A

Provider Performance

N/A

Reception Center

N/A

N/A

Specialized Medical Housing
Specialty Services
Administrative Operations †

N/A

* The symbols in this column correspond to changes that occurred in indicator ratings between
the medical inspections conducted during Cycle 5 and Cycle 6. The equals sign means there
was no change in the rating. The single arrow means the rating rose or fell one level, and the
double arrow means the rating rose or fell two levels (green, from inadequate to proficient;
pink, from proficient to inadequate).
† Administrative Operations is a secondary indicator and is not considered when rating the
institution’s overall medical quality.
Source: The Office of the Inspector General medical inspection results.

Report Issued: April 2021

Office of the Inspector General, State of California

Return to Contents

4

Cycle 6 Medical Inspection Report

To test the institution’s policy compliance, our compliance inspectors
(a team of registered nurses) monitored the institution’s compliance
with its medical policies by answering a standardized set of questions
that measure specific elements of health care delivery. Our compliance
inspectors examined 402 patient records and 1,266 data points and used
the data to answer 92 policy questions. In addition, we observed COR’s
processes during an on-site inspection in March 2020. Table 2 below lists
COR’s average scores from Cycles 4, 5, and 6.
OIG case review clinicians (a team of physicians and nurse consultants)
reviewed 57 cases, which contained 957 patient-related events. After
examining the medical records, our clinicians conducted a follow-up
on-site inspection in July 2020 to verify their initial findings. The OIG
physicians rated the quality of care for 20 comprehensive case reviews.

Table 2. COR Policy Compliance Scores

Scoring Ranges
100% – 85.0%

Medical
Inspection
Tool (MIT)

84.9% – 75.0%

74.9% – 0

Average Score
Policy Compliance Category

Cycle 4

Cycle 5

Cycle 6

1

Access to Care

68.9%

81.1%

80.0%

2

Diagnostic Services

69.1%

74.8%

49.6%

4

Health Information Management

65.8%

67.2%

89.9%

5

Health Care Environment

70.2%

70.7%

45.8%

6

Transfers

53.1%

43.0%

51.2%

7

Medication Management

59.1%

56.1%

51.4%

8

Prenatal and Postpartum Care

N/A

N/A

N/A

9

Preventive Services

68.6%

87.0%

59.8%

N/A

N/A

N/A

12

Reception Center

13

Specialized Medical Housing

70.0%

76.7%

85.0%

14

Specialty Services

64.2%

77.3%

71.6%

15

Administrative Operations

65.2%

65.2%

71.9%

* In Cycle 4, there were two secondary (administrative) indicators, and this score reflects
the average of those two scores. In Cycle 5 and moving forward, the two indicators
were merged into one, with only one score as the result.
Source: The Office of the Inspector General medical inspection results.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

5

Of these 20 cases, our physicians rated 14 adequate and six inadequate.
Our physicians did not find any adverse events during this inspection.
The OIG then considered the results from both case review and
compliance testing and drew overall conclusions, which we report in the
13 health care indicators.7 Multiple OIG physicians and nurses performed
quality control reviews; their subsequent collective deliberations ensured
consistency, accuracy, and thoroughness. Our clinicians acknowledged
institutional structures that catch and resolve mistakes which may occur
throughout the delivery of care. As noted above, we listed the individual
indicators and ratings applicable for this institution in Table 1, the
COR Summary Table.
In February 2020, the Health Care Services Master Registry showed that
COR had a total population of 2,976. A breakdown of the medical risk
level of the COR population as determined by the department is set forth
in Table 3 below.8

Table 3. COR Master Registry Data as of February 2020
Medical Risk Level

Number of Patients

Percentage

High 1

17

2.5%

High 2

196

6.6%

Medium

1,413

47.5%

Low

1,293

43.4%

Total

2,976

100%

Source: Data for the population medical risk level were obtained from
the CCHCS Master Registry dated 2-28-20.

7. The indicators for Reception Center and Prenatal Care do not apply to COR.
8. For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9.

Report Issued: April 2021

Office of the Inspector General, State of California

Return to Contents

6

Cycle 6 Medical Inspection Report

Based on staffing data the OIG obtained from California Correctional
Health Care Services (CCHCS), as identified in Table 4 below, COR
had 1.4 vacant primary care provider positions and 12.4 vacant nursing
staff positions.

Table 4. COR Health Care Staffing Resources as of February 2020

Positions

Executive
Leadership *

Primary Care
Providers

Nursing
Supervisors

Nursing
Staff †

Total

Authorized Positions

6

9.4

21.2

197.5

234.1

Filled by Civil Service

6

8

21

213.5

248.5

Vacant

0

1.4

0.2

12.4

28

100%

85.1%

99.1%

108.1%

106.2%

0

0

2

0

0

0.9%

Percentage Filled by Civil Service
Filled by Telemedicine

0

Percentage Filled by Telemedicine

0

Filled by Registry

0

0

0

35

35

Percentage Filled by Registry

0

0

0

17.7%

15%

Total Filled Positions

6

10

Total Percentage Filled

100%

2
21.3%

106.4%

21

248.5

285.5

99.1%

125.8%

102.8%

Appointments in Last 12 Months

2

2

5

55

64

Redirected Staff

0

0

0

1

1

Staff on Extended Leave ‡

0

1

0

8

9

Adjusted Total: Filled Positions

6

9

21

239.5

275.5

99.1%

121.3%

117.7%

Adjusted Total: Percentage Filled

100%

95.8%

* Executive Leadership includes the Chief Physician and Surgeon.
† Nursing Staff includes Senior Psychiatric Technician and Psychiatric Technician.
‡ In Authorized Positions.

Notes: The OIG does not independently validate staffing data received from the department. Positions are based on
fractional time-base equivalents.
Source: Cycle 6 medical inspection preinspection questionnaire staffing matrix received February 2020,
from California State Prison, Corcoran.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

7

Medical Inspection Results
Deficiencies Identified During Case Review
Deficiencies are medical errors that increase the risk of patient harm.
Deficiencies can be minor or significant, depending on the severity of
the deficiency.
An adverse event occurs when the deficiency caused harm to the patient.
All major health care organizations identify and track adverse events. We
identify deficiencies and adverse events to highlight concerns regarding
the provision of care and for the benefit of the institution’s quality
improvement program to provide an impetus for improvement.9
Our inspectors did not find any adverse events at COR during the
Cycle 6 inspection.

Case Review Results
OIG case reviewers (a team of physicians and nurse consultants) assessed
10 of the 13 indicators applicable to COR. Of these 10 indicators,
OIG clinicians rated seven adequate and three inadequate. The OIG
physicians also rated the overall adequacy of care for each of the
20 detailed case reviews they conducted. Of these 20 cases, 14 were
adequate and six were inadequate. Our clinicians reviewed 957 events
and identified 270 deficiencies, 61 of which they considered to be of
such magnitude that, if left unaddressed, would likely contribute to
patient harm.
Our clinicians found the following strengths at COR:
• Access to care was good, and provider, nurse, and specialty
appointments in the CTC were timely.
• The institution performed well in obtaining hospital discharge
reports, scanning, and labeling medical records.
• Providers and nurses delivered good care with emergency
services and in specialized medical housing units.
Our clinicians found room for improvement in the following areas:
• COR should improve transfer processes to ensure continuity of
specialty referrals and medication.
• Providers should document their emergency care completely and
accurately.
• Nursing staff should improve assessments and documentation in
the outpatient and emergency settings.
• COR should improve medication administration processes.
• COR should improve care for hypoglycemic diabetic patients.
9. For a further discussion of an adverse event, see Table A–1.

Report Issued: April 2021

Office of the Inspector General, State of California

Return to Contents

8

Cycle 6 Medical Inspection Report

Compliance Testing Results
Our compliance inspectors assessed 10 of the 13 indicators applicable
to COR. Of these 10 indicators, our compliance inspectors rated two
proficient, one adequate, and seven inadequate. We tested only policy
compliance in the Health Care Environment, Preventive Services, and
Administrative Operations indicators as these indicators do not have a
case review component.
COR demonstrated a high rate of policy compliance in the
following areas:
• Staff maintained adequate supplies of sick-call forms and
designated lock boxes in housing units.
• Nursing staff completed initial assessments of patients admitted
to specialized medical housing within the required time frame.
• Providers performed history and physical examinations timely
for patients admitted to specialized medical housing.
COR demonstrated a low rate of policy compliance in the
following areas:
• Providers often did not create patient letters when
communicating diagnostic test results.
• Patients did not receive their chronic care medications, newly
ordered medications, and hospital discharge medications
timely. There was also poor medication continuity for patients
transferring in from other facilities, transferring within the
facility, and layover patients.
• Health care staff poorly monitored patients taking tuberculosis
(TB) medications.
• Clinics and the medical warehouse stored medical supplies
beyond manufacturers’ guidelines.
• Health care staff did not regularly follow universal hand hygiene
precautions during patient encounters.

Population-Based Metrics
In addition to our own compliance testing and case reviews, as noted
above, the OIG presents selected measures from the Healthcare
Effectiveness Data and Information Set (HEDIS) for comparison
purposes. The HEDIS is a set of standardized quantitative performance
measures designed by the National Committee for Quality Assurance to
ensure that the public has the data it needs to compare the performance
of health care plans. Because the Veterans Administration no longer
publishes its individual HEDIS scores, we removed them from our
comparison for Cycle 6. Likewise, Kaiser (commercial plan) no longer
publishes HEDIS scores, but the OIG obtained Kaiser Medi‑Cal HEDIS
scores through the California Department of Health Care Services’

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

9

Medi‑Cal Managed Care Technical Report to use in conducting our analysis,
and we present them here for comparison.

HEDIS Results
We considered COR’s performance with population-based metrics to
assess the macroscopic view of the institution’s health care delivery.
COR’s results compared favorably with those found in State health plans
for diabetic care measures. We list the five HEDIS measures in Table 5.
Comprehensive Diabetes Care
When compared with statewide Medi-Cal programs (California
Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern
California (Medi-Cal) ), COR performed better in three of the five diabetic
measures. The institution scored lower than Kaiser Southern California
(Medi-Cal) for blood pressure control and scored lower than all Medi-Cal
programs for eye examinations.
Immunizations
Statewide comparative data were not available for immunization
measures; however, we include these data for informational purposes.
COR had a 40 percent influenza immunization rate for adults 18 to
64 years old, and a 57 percent influenza immunization rate for adults
65 years of age and older.10 The pneumococcal vaccines are only
administered once for patients who are older than 65 years of age;
therefore, the vaccine may not have occurred during the inspection
period. The pneumococcal vaccination rate was 80 percent.
Colorectal Cancer Screening
Statewide comparative data were not available for colorectal cancer
screening; however, we include these data for informational purposes.
COR had a 67 percent colorectal cancer screening rate.

10. The pneumococcal vaccines administered are the 13 valent pneumococcal vaccine
(PCV13) or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical
conditions. For the adult population, the influenza or pneumococcal vaccine may have been
administered at a different institution other than the one in which the patient was currently
housed during the inspection period.

Report Issued: April 2021

Office of the Inspector General, State of California

Return to Contents

10

Cycle 6 Medical Inspection Report

Table 5. COR Results Compared With State HEDIS Scores

COR
HEDIS Measure
HbA1c Screening

Cycle 6
Results *

California
Medi-Cal
2018 †

California
Kaiser
NorCal
Medi-Cal
2018  †

California
Kaiser
SoCal
Medi-Cal
2018  †

100%

88%

94%

95%

Poor HbA1c Control (> 9.0%) ‡,§

12%

34%

24%

20%

HbA1c Control (< 8.0%) ‡

79%

55%

62%

70%

Blood Pressure Control (< 140/90) ‡

84%

67%

75%

85%

Eye Examinations

36%

63%

77%

83%

Influenza – Adults (18 – 64)

40%

–

–

–

Influenza – Adults (65 +)

57%

–

–

–

Pneumococcal – Adults (65 +)

80%

–

–

–

Colorectal Cancer Screening

67%

–

–

–

Notes and Sources
* Unless otherwise stated, data were collected in March 2020 by reviewing medical records from a
sample of COR’s population of applicable patients. These random statistical sample sizes were based on
a 95 percent confidence level with a 15 percent maximum margin of error.
† HEDIS Medi-Cal data were obtained from the California Department of Health Care Services

publication titled, Medi-Cal Managed Care External Quality Review Technical Report, dated
July 1, 2017 – June 30, 2018 (published April 2019).

‡ For this indicator, the entire applicable COR population was tested.
§ For this measure only, a lower score is better.

Source: Institution information provided by the California Department of Corrections and Rehabilitation.
Health Care plan data obtained from the CCHCS Master Registry.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

11

Recommendations
As a result of our assessment of COR’s performance, we offer the
following recommendations to the department. Where we recommend
an internal review of the root cause of identified problems, we further
recommend that the institution consider all remedial measures
to address challenges, including both systemic adjustments and
individual accountability:
Access to Care
• Medical leadership should determine the root cause of
challenges in the timely provision of chronic care appointments
with providers, nurse-to-provider referrals, and follow-up
specialty appointments and implement remedial measures
as appropriate.
Diagnostic Services
• Medical leadership should determine the root cause of
challenges with scanning, retrieving, and reviewing of laboratory,
radiology, and pathology results and implement remedial
measures as appropriate to ensure they are performed within
required time frames.
• Medical leadership should ascertain causative factors with timely
provision of pathology and laboratory results letters to patients
and implement remedial measures as appropriate.
• The department should consider developing and implementing
a patient results letter template which autopopulates with all
elements required per CCHCS policy.
Emergency Services
• Medical leadership should determine the root cause of
challenges with providers’ completion of progress notes
for emergent events and implement remedial measures as
appropriate to ensure they are completed.
• The Emergency Medical Response Review Committee (EMRRC)
should identify and address delays in the transfer of patients
to a higher level of care, including delays due to availability of
custody staff.
• Nursing leadership should identify root causes that prevent
nurses from completely and accurately documenting assessments
and medication administration in emergent events and
implement remedial measures as appropriate.
Health Information Management
• Medical leadership should determine the root cause of
challenges in timely scanning, retrieving, and reviewing specialty

Report Issued: April 2021

Office of the Inspector General, State of California

Return to Contents

12

Cycle 6 Medical Inspection Report

service reports and implement remedial measures as appropriate
to ensure they are performed within required time frames.
Health Care Environment
• Nursing leadership should consider performing random spot
checks to ensure staff follow equipment and medical supply
management protocols.
• Medical leadership should remind staff to follow universal hand
hygiene precautions. Implementing random spot checks could
improve compliance.
• Nursing leadership should have each clinic nurse supervisor
review the monthly EMRB logs to ensure the EMRBs are
regularly inventoried and sealed.
Transfers
• Nursing leadership should determine the cause of challenges
in providing medications to newly arriving patients without
interruption and implement remedial measures as appropriate.
• The department should consider developing and implementing
an electronic alert to ensure nurses in receiving and release
(R&R) properly complete initial health screening questions and
follow up as needed.
Medication Management
• Medical leadership should determine the cause of challenges
related to medication continuity for chronic care, transferin, hospital discharge, and en route patients and implement
remedial measures as appropriate.
Preventative Services
• Medical leadership should remind nursing staff to perform
weekly monitoring and address the symptoms of patients taking
TB medications.
Nursing Performance
• Nursing leadership should consider implementing a
performance review or audit to ensure nurses properly intervene
when patients present with acute medical symptoms and notify
providers of abnormal values timely.
• Nursing leadership should review the cause of lapses in chronic
care coordination for diabetic patients and implement remedial
measures as appropriate.
• Nursing leadership should determine the root cause of
challenges that prevent outpatient and special housing nurses
from performing complete assessments and documentation

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

13

of care accurately and implement remedial measures
as appropriate.
Provider Performance
• Medical leadership should ascertain causative factors in the
timely provider review of hospital and specialty reports and with
provider follow through of recommendations. Medical leadership
should implement remedial measures as appropriate.
Specialized Medical Housing
• Nursing leadership should determine the root cause of
challenges in ensuring patients who are admitted into the CTC
and OHU receive their medications timely upon admission and
implement remedial measures as appropriate.
Specialty Services
• Nursing leadership should determine the root cause of
challenges in nurses’ review of specialty reports and challenges
of informing providers of specialists’ recommendations and
implement remedial measures as appropriate.
• Medical leadership should identify the root cause in timely
provision of ordered specialty services and implement remedial
measures as appropriate.
Administrative Operations
• The medical and nursing leadership should ensure clinical
competency evaluations and performance appraisals are
completed timely.

Report Issued: April 2021

Office of the Inspector General, State of California

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14

Cycle 6 Medical Inspection Report

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Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

Access to Care
In this indicator, OIG inspectors evaluated the institution’s ability to
provide patients with timely clinical appointments. Our inspectors
reviewed the scheduling and appointment timeliness for newly arrived
patients, sick calls, and nurse follow-up appointments. We examined
referrals to primary care providers, provider follow-ups, and specialists.
Furthermore, we evaluated the follow-up appointments for patients who
received specialty care or returned from an off-site hospitalization.

Results Overview
COR provided good access to care. Most provider, nurse, and specialty
appointments in the correctional treatment center (CTC) were completed
timely. Our clinicians found COR had room for improvement in timely
appointments for specialty follow up, provider chronic care, and nurse
referrals to providers. Overall, the OIG rated this indicator adequate.

15

Overall
Rating

Adequate
Case Review
Rating
Adequate
Compliance
Score
Adequate
(80.0%)

Case Review Results
We reviewed 264 provider, nursing, specialty, and hospital events that
required the institution to generate appointments. We identified 19
deficiencies relating to Access to Care, 13 of which were significant.11
Access to Clinic Providers
COR had a mixed performance with access to providers. Compliance
testing showed chronic care follow-up visits occurred within the
ordered time frames at a rate of 64.0 percent (MIT 1.001). Four of the
nine compliance samples that did not meet time frames were less than
10 days late. When sick call nurses referred their patients to a provider,
the provider appointments occurred about half the time (MIT 1.005,
58.3%). In four of these samples, the patients were seen within seven
days. Only seven of the 13 patients were seen within the required time
frames. When providers ordered follow-up appointments for sick-call
conditions, patients were always seen within the ordered time frames
(MIT 1.006, 100%).
Our case review found four deficiencies related to provider access,12 three
of which are illustrated in the cases below:
• In case 10, the provider ordered a provider chronic care
appointment. However, the appointment was scheduled for two
months later.
• In case 18, the patient was seen in the triage and treatment area
(TTA). The provider ordered a provider follow-up appointment
for the next day, but it was not scheduled for the next day.
11. Deficiencies occurred in cases 10, 15, 16, 18, 19, 21, 22, 36, 45, 48, 49, 51, 52, 53, and 55.
Significant deficiencies occurred in cases 10, 15, 16, 18, 19, 22, 45, 48, 49, 51, 53, and 55.
12. Deficiencies occurred in cases 10, 18, 36, and 52.

Report Issued: April 2021

Office of the Inspector General, State of California

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16

Cycle 6 Medical Inspection Report

• In case 52, the provider discharged the patient from the
outpatient housing unit (OHU) without ordering a five-day
provider follow-up appointment, as per policy. A provider saw
the patient a month later.
Access to Specialized Medical Housing Providers
COR performed well with provider access in the CTC. When staff
admitted patients to the CTC, providers performed history and
physicals on patients timely. Compliance testing showed similar results;
COR scored 100 percent (MIT 13.002). The OIG clinicians assessed
62 CTC provider encounters and did not identify any missed or late
provider appointments.
Access to Clinic Nurses
As in Cycle 5, COR nurses performed well with same-day triage of sick
call requests. The compliance testing result corroborated our case review
finding (MIT 1.003, 87.5%). For RN sick call appointments, compliance
testing showed these appointments generally occurred within one
business day (MIT 1.004, 87.5%). In our case reviews, we identified
occasional delays and lapses in the following cases:
• In cases 15 and 48, the RN sick-call appointment occurred
one and two days late, respectively.
• In cases 45, 48, and 49, the RN sick-call appointments did not
occur.
RN care management and care coordination visits occurred within
specified time frames. Provider-to-nurse referrals also occurred within
the requested time frames with the exception of two cases:
• In case 18, the RN follow-up appointment occurred four
days late.
• In case 36, the RN follow-up appointment occurred three
days late.
Overall, patients’ access to clinic nurses was satisfactory.
Access to Specialty Services
Compliance testing showed very good specialty access for high-priority
(MIT 14.001, 93.3%), medium-priority (MIT 14.004, 80.0%), and routinepriority appointments (MIT 14.007, 100%). Case reviewers found patients
not receiving appointments or receiving delayed specialty appointments
in case 16 and the following case:
• In case 53, the provider ordered an urgent orthopedic
appointment to perform a aspiration procedure on the patient’s
hip; however, the patient did not receive the appointment within
the urgent time frame.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

17

When specialists requested follow-up appointments, staff
generally scheduled the requested appointments timely
(MIT 14.003, 80.0%; MIT 14.006, 75.0%; and MIT 14.009, 70.0%).
Our case reviewers found patients did not receive or received
delayed specialty follow-up appointments in cases 19, 51, and the
following case:
• In case 15, the provider ordered a follow-up cardiology
appointment to review the patient’s heart test results; however,
the patient did not receive the appointment.
Follow-up After Specialty Service
Staff generally arranged for provider follow-up appointments following
specialty consultations. Compliance testing results reflected this good
performance (MIT 1.008, 81.0%). In case review, our clinicians found only
one deficiency:
• In case 21, the patient returned from hand surgery. The nurse
planned to order a provider follow-up appointment in three days,
but instead ordered a 14-day follow-up appointment.
Follow-up After Hospitalization
After returning from an off-site hospitalization, patients were often
scheduled follow-up appointments with a provider. Compliance testing
results showed these follow-up appointments occurred within the
required time frames 78.3 percent of the time (MIT 1.007). The OIG
clinicians reviewed 21 hospital returns and did not identify any missed or
delayed appointments.
Follow-up After Urgent or Emergent Care (TTA)
COR providers saw patients promptly after they received urgent or
emergent care in the TTA. Our clinicians reviewed 55 TTA events
and did not find any missed or delayed provider or nurse follow up
appointments. The Emergency Services indicator discusses urgent and
emergent patient care in more detail.
Follow-up After Transferring Into the Institution
COR generally performed well with ensuring provider access for patients
who recently transferred into the institution. Our compliance inspectors
found most patients saw a provider timely after arrival (MIT 1.002,
80.0%). Our clinicians reviewed three transfer-in cases and did not find
any deficiencies.
Clinician On-Site Inspection
We interviewed the leadership, supervisors, utilization management
(UM), office technicians, and nurses regarding access to care. We were
informed that during the review months, providers underwent training

Report Issued: April 2021

Office of the Inspector General, State of California

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18

Cycle 6 Medical Inspection Report

for the electronic medical records, hepatitis C management, and
licensing for substance abuse treatment. In addition, providers were out
ill and on vacation. Training and absences resulted in backlogs. COR
currently has two telemedicine providers to deliver primary care access.
The UM and supervisors reported that the institution reduced access
to the limited available providers for a few specialty services, such
as cardiology. For the previous three months, COR implemented an
online consultation referral process. Providers consult with a specialist
and receive a response sooner than they would with an in-person
appointment. Medical leadership and providers agree this has helped the
institution with specialty access.
Our on-site inspection occurred during the COVID-19 pandemic. We
observed all staff wearing masks and practicing social distancing when
possible. Providers were still seeing patients with urgent conditions,
but nonurgent appointments were moved to a later date. Some off-site
specialists had closed their clinics, which affected in-person specialty
appointments.

Recommendations
• Medical leadership should determine the root cause of
challenges in timely provision of chronic care appointments with
providers, nurse-to-provider referrals, and follow-up specialty
appointments and implement remedial measures as appropriate.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

19

Compliance Testing Results
Table 6. Access to Care

Scored Answer

Compliance Questions

Yes

No

Chronic care follow-up appointments: Was the patient’s most
recent chronic care visit within the health care guideline’s maximum
allowable interval or within the ordered time frame, whichever is
shorter? (1.001) *

16

9

0

64.0%

For endorsed patients received from another CDCR institution: Based
on the patient’s clinical risk level during the initial health screening,
was the patient seen by the clinician within the required time frame?
(1.002) *

20

5

0

80.0%

Clinical appointments: Did a registered nurse review the patient’s
request for service the same day it was received? (1.003) *

35

5

0

87.5%

Clinical appointments: Did the registered nurse complete a face-toface visit within one business day after the CDCR Form 7362 was
reviewed? (1.004) *

35

5

0

87.5%

Clinical appointments: If the registered nurse determined a referral to
a primary care provider was necessary, was the patient seen within the
maximum allowable time or the ordered time frame, whichever is the
shorter? (1.005) *

7

5

28

58.3%

Sick call follow-up appointments: If the primary care provider ordered
a follow-up sick call appointment, did it take place within the time
frame specified? (1.006) *

2

0

38

Upon the patient’s discharge from the community hospital: Did the
patient receive a follow-up appointment within the required time
frame? (1.007) *

18

5

2

78.3%

Specialty service follow-up appointments: Did the clinician follow-up
visits occur within required time frames? (1.008) *,†

34

8

3

81.0%

5

1

0

83.3%

Clinical appointments: Do patients have a standardized process to
obtain and submit health care services request forms? (1.101)

N/A

Yes %

100%

Overall percentage (MIT 1): 80.0%
* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.

† CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician
follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority
specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness
of specialty follow-ups through its case review testing.

Source: The Office of the Inspector General medical inspection results.

Report Issued: April 2021

Office of the Inspector General, State of California

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20

Cycle 6 Medical Inspection Report

Table 7. Other Tests Related to Access to Care
Scored Answer
Compliance Questions

Yes

No

N/A

Yes %

For patients received from a county jail: If, during the assessment, the
nurse referred the patient to a provider, was the patient seen within the
required time frame? (12.003) *

N/A

N/A

N/A

N/A

For patients received from a county jail: Did the patient receive a
history and physical by a primary care provider within seven calendar
days? (12.004) *

N/A

N/A

N/A

N/A

For CTC and SNF only (effective 4/2019, include OHU): Was a written
history and physical examination completed within the required time
frame? (13.002) *

10

0

0

100%

N/A

N/A

N/A

N/A

14

1

0

93.3%

Did the patient receive the subsequent follow-up to the high-priority
specialty service appointment as ordered by the primary care provider?
(14.003) *

8

2

5

80.0%

Did the patient receive the medium-priority specialty service within
15-45 calendar days of the primary care provider order or the Physician
Request for Service? (14.004) *

12

3

0

80.0%

6

2

7

75.0%

15

0

0

7

3

5

For OHU, CTC, SNF, and Hospice (applicable only for samples prior to
4/2019): Did the primary care provider complete the Subjective, Objective,
Assessment, and Plan notes on the patient at the minimum intervals
required for the type of facility where the patient was treated? (13.003) *,†
Did the patient receive the high-priority specialty service within
14 calendar days of the primary care provider order or the Physician
Request for Service? (14.001) *

Did the patient receive the subsequent follow-up to the mediumpriority specialty service appointment as ordered by the primary care
provider? (14.006) *
Did the patient receive the routine-priority specialty service within
90 calendar days of the primary care provider order or Physician
Request for Service? (14.007) *
Did the patient receive the subsequent follow-up to the routine-priority
specialty service appointment as ordered by the primary care provider?
(14.009) *

100%

70.0%

* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.
† CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located
in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still had statemandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider
follow-ups within specialized medical housing units through case reviews.
Source: The Office of the Inspector General medical inspection results.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

Diagnostic Services
In this indicator, OIG inspectors evaluated the institution’s ability
to timely complete radiology, laboratory, and pathology tests. Our
inspectors determined whether the institution properly retrieved the
resultant reports and whether providers reviewed the results correctly.
In addition, in Cycle 6, we examined the institution’s ability to timely
complete and review stat (immediate) laboratory tests.

Results Overview
COR had variable performance in this indicator. COR performed well
in radiology test completion and provider review of laboratory and
pathology results. However, the institution faltered in completing
laboratory tests and retrieving pathology results timely. Additionally,
providers often did not send patient letters for laboratory and pathology
results. COR’s poor compliance performance weighed heavily in our
rating for this indicator, which we rated inadequate.

21

Overall
Rating

Inadequate
Case Review
Rating
Adequate
Compliance
Score
Inadequate
(49.6%)

Case Review Results
The OIG clinicians reviewed 117 diagnostic events and found 30
deficiencies, six of which were significant. Of the 30 deficiencies, 24 were
related to health information management and 4 pertained to completing
diagnostic tests.13 For health information management, we considered
test reports that were never retrieved or reviewed as severe of a problem
as tests that were not performed.
Test Completion
Compliance testing showed COR often completed radiology tests within
the required time frames (MIT 2.001, 80.0%). Our clinicians also found
similar results in case reviews, with the exception of case 55 and the
following case:
• In case 2, the provider ordered the patient have a neck X-ray in
14 days; however, the appointment was not scheduled, and the
patient did not receive the X-ray.
In contrast to the radiology completion rate, laboratory tests were
completed within the specified time frames at a lower rate (MIT 2.004,
50.0%). This rate was lower than the institution’s rate of 100 percent
during Cycle 5 for the same test. Detailed review of the compliance cases
showed the laboratory tests were completed between one and six days
late. The following cases also show delays in laboratory test completion:
• In case 9, the provider ordered laboratory tests to be performed
on a specific date; however, the tests were done eight days late.

13. Deficiencies occurred in cases 1, 2, 8, 9, 11, 12, 15, 18, 19, 22, 23, 50, 51, 54, 55, and 57.
Significant deficiencies occurred in cases 2, 12, 18, 19, 55, and 57.

Report Issued: April 2021

Office of the Inspector General, State of California

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22

Cycle 6 Medical Inspection Report

• In case 18, the provider ordered a blood count laboratory test to
be performed on a specific date, instead the test was scheduled
to be performed six days late.
Compliance testing did not have applicable samples for the evaluation
of STAT laboratory test completion (MIT 2.007, N/A). Our case
review clinicians did not find any deficiencies in STAT laboratory
test completion; however, in one case a STAT radiology test was
performed late:
• In case 55, the provider evaluated the patient and ordered
a STAT abdominal X-ray; however, it was performed four
days later.
Health Information Management
COR had mixed results in diagnostic health information management.
Our compliance testing showed providers reviewed laboratory reports on
time (MIT 2.005, 100%). However, our case review clinicians found seven
instances of delayed review of laboratory test results.14 Some examples
include the following cases:
• In case 12, the provider endorsed the laboratory reports ten days
after the results were available.
• In case 51, the provider endorsed the laboratory reports fifteen
days after the results were available.
The providers communicated laboratory test results to patients within
specified time frames at a low rate (MIT 2.006, 10.0%). Our case review
clinicians found that a provider did not send a laboratory result letter in
case 54.
The providers endorsed radiology reports within specified time frames
at a low rate (MIT 2.002, 66.7%). In two of the compliance samples, we
found no evidence the provider endorsed the radiology report. Our case
review clinicians found examples of providers not reviewing or endorsing
radiology reports late in the following cases:
• In case 1, the provider ordered an abdominal X-ray; however, the
results were not endorsed by a provider.
• In case 51, the provider endorsed the chest X-ray results nine
days after they were available.
COR had variable scores with handling of pathology results in
compliance testing. COR retrieved pathology reports 40.0 percent of the
time (MIT 2.010). In the compliance samples, three pathology results
were obtained one to 70 days late, while in three other samples, the final
pathology results were not retrieved. Our case review clinicians also
identified a delay in the following case:
• In case 18, the patient had an esophageal biopsy performed, but
the biopsy results were retrieved over five months later.
14. This deficiencies occurred in cases 1, 12, 18, 51, 54, and 57.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

23

Compliance testing showed providers performed well endorsing
pathology results (MIT 2.011, 100%). However, the providers did not send
result letters to the patients within the required time frames (MIT 2.012,
zero). On further review of these compliance samples, we confirmed
that although providers did not send result letters to their patients,
they did discuss the pathology results with their patients at subsequent
appointments. This correlated with our case review clinicians’ findings.
Compliance testing did not have applicable samples for the evaluation of
STAT laboratory test results management by the nurse and provider (MIT
2.008, 2.009, N/A). Case review clinicians did not find any deficiencies in
handling of STAT laboratory test results.
Clinician On-Site Inspection
During our on-site inspection, we interviewed COR leadership,
providers, supervisors, and staff regarding their diagnostic processes.
Providers reported good laboratory services; however, radiology staff
reported the X-ray machine was broken from September 2019 to
May 2020. X-rays had to be performed at a nearby institution or at the
local hospital, accounting for some delays in the ordered X-rays during
the review period. Since this time, the X-ray machine has been repaired
and COR now has no X-ray backlogs. Furthermore, ancillary service
leadership reported implementing tracking logs to monitor timely test
completion. The chief medical executive (CME) and chief physician and
surgeon (CP&S) also audit providers monthly to ensure laboratory and
radiology tests are reviewed within the required time frames.

Recommendations
• Medical leadership should determine the root cause of
challenges with scanning, retrieving, and reviewing of laboratory,
radiology, and pathology results and implement remedial
measures as appropriate to ensure they are performed within
required time frames.
• Medical leadership should ascertain causative factors with timely
provision of pathology and laboratory results letters to patients
and implement remedial measures as appropriate.
• The department should consider developing and implementing
a patient results letter template which autopopulates with all
elements required per CCHCS policy.

Report Issued: April 2021

Office of the Inspector General, State of California

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24

Cycle 6 Medical Inspection Report

Compliance Testing Results
Table 8. Diagnostic Services
Scored Answer
Compliance Questions

Yes

No

Radiology: Was the radiology service provided within the time frame
specified in the health care provider’s order? (2.001) *

8

2

0

80.0%

Radiology: Did the ordering health care provider review and endorse
the radiology report within specified time frames? (2.002) *

6

3

1

66.7%

Radiology: Did the ordering health care provider communicate the
results of the radiology study to the patient within specified time
frames? (2.003)

0

9

1

Laboratory: Was the laboratory service provided within the time frame
specified in the health care provider’s order? (2.004) *

5

5

0

10

0

0

1

9

0

Laboratory: Did the institution collect the STAT laboratory test and
receive the results within the required time frames? (2.007) *

N/A

N/A

N/A

N/A

Laboratory: Did the nursing staff notify the health care provider within
one (1) hour from receiving the STAT laboratory results? (2.008) *

N/A

N/A

N/A

N/A

Laboratory: Did the health care provider endorse the STAT laboratory
results within the required time frames? (2.009)

N/A

N/A

N/A

N/A

Pathology: Did the institution receive the final pathology report within
the required time frames? (2.010) *

4

6

0

Pathology: Did the health care provider review and endorse the
pathology report within specified time frames? (2.011) *

7

0

3

100%

Pathology: Did the health care provider communicate the results
of the pathology study to the patient within specified time frames?
(2.012)

0

7

3

0

Laboratory: Did the health care provider review and endorse the
laboratory report within specified time frames? (2.005) *
Laboratory: Did the health care provider communicate the results of
the laboratory test to the patient within specified time frames? (2.006)

N/A

Yes %

0

50.0%
100%
10.0%

40.0%

Overall percentage (MIT 2): 49.6%
* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.
Source: The Office of the Inspector General medical inspection results.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

Emergency Services
In this indicator, OIG clinicians evaluated the quality of emergency
medical care. Our clinicians reviewed emergency medical services by
examining the timeliness and appropriateness of clinical decisions
made during medical emergencies. Our evaluation included examining
the emergency medical response, cardiopulmonary resuscitation (CPR)
quality, triage and treatment area (TTA) care, provider performance,
and nursing performance. Our clinicians also evaluated the Emergency
Medical Response Review Committee’s (EMRRC) ability to identify
problems with its emergency services. The OIG assessed the institution’s
emergency services through case review only; we did not perform
compliance testing for this indicator.

25

Overall
Rating

Adequate
Case Review
Rating
Adequate
Compliance
Score
(N/A)

Results Overview
COR’s overall performance in this indicator was similar to Cycle 5. COR
generally delivered prompt life support care during medical emergencies.
Providers performed adequate evaluations for patients and delivered
appropriate interventions. Areas for improvement included delays in
transferring patients to the TTA and community hospital and first
medical responder and nursing assessment and documentation. We rated
this indicator adequate.

Case Review Results
Our clinicians reviewed 19 cases with 55 urgent or emergent events and
found 43 emergency care deficiencies, seven of which were significant.15
Emergency Medical Response
Staff responded promptly to emergencies throughout the institution,
they initiated CPR, activated emergency medical services (EMS), and
notified TTA staff in a timely manner. First medical responders generally
performed initial assessments at the scene and provided appropriate
medical interventions.
• Similar to Cycle 5, we identified delays in staff calling 9-1-1 and
transferring patients to a higher level of care.16 The following
cases illustrate these deficiencies:
• In case 2, the patient had an altered mental status and a potential
head injury. Staff did not call community EMS until 22 minutes
after they found the patient. Also, the patient’s departure was
delayed for 20 minutes because EMS could not depart without a
custody escort.

15. Deficiencies occurred in cases 1, 2, 4, 5, 6, 7, 8, 9, 18, 22, 23, 55, and 57. Significant
deficiencies occurred in cases 2, 9, 18, 22, 55, and 57.
16. Delays in emergency medical response occurred in cases 2, 8, and 55.

Report Issued: April 2021

Office of the Inspector General, State of California

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Cycle 6 Medical Inspection Report

• In cases 8 and 55, the transportation team was not ready when
community EMS arrived, which delayed the patient’s transfer to
the community hospital.
Provider Performance
Providers performed adequately in evaluating patients with urgent
or emergent conditions in the TTA. Providers were available for
consultation with TTA nursing staff during the day and after hours.
The providers usually examined, diagnosed, and triaged these patients
appropriately. OIG clinicians identified 12 deficiencies, some related to
decision making, but the majority related to documentation lapses.17 The
following cases detail some of the deficiencies found:
• In case 9, the diabetic patient, who had a history of low and
high sugar fluctuations, was evaluated in the TTA. The provider
should have scheduled a provider follow-up appointment within
five days for this high-risk patient to ensure close follow-up;
however, the provider did not.
• In case 55, the patient had an elevated heart rate which the
provider did not address before medically clearing the patient.
Furthermore, when the patient swallowed a razor blade, the
provider did not order X-rays to determine the location of the
razor blade the same day, but had it performed three days later.
• In cases 9, 18, 23, 55, and 57, the providers were consulted on
the patients in the TTA, but they did not document complete
progress notes.
Nursing Performance
Nursing performance during medical emergencies had similar
deficiencies identified in Cycle 5. First medical responders occasionally
did not perform an initial assessment or provide appropriate
interventions. When staff transferred patients to the TTA, the TTA
nurses sometimes did not properly evaluate and monitor the patients;
however, the nursing deficiencies did not significantly affect the patient’s
care and outcome, but are opportunities for improvement. Examples of
first medical responder deficiencies we identified are illustrated in the
following cases:
• In case 2, the patient had face and head injuries and received
emergency care. The TTA nurse removed a cervical collar
prior to the on-site provider clearing the patient. Additionally,
neurological checks were not completed every 15 minutes, as
required per nursing protocol for this level of consciousness,
while the patient was waiting for transfer to a higher level
of care.

17. Deficiencies occurred in cases 9, 18, 23, 55, and 57. Significant deficiencies occurred in
cases 9 and 55.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

27

• In case 5, custody staff found the patient unresponsive
and suspected a drug overdose. The nurse did not check
the patient’s pulse or pupil size and did not immediately
administer naloxone.18
• The following cases show some opportunities for improvement
we identified in TTA nursing performance:
• In case 9, the diabetic patient reported he had a seizure, which
could be caused by significantly low blood sugar; however, the
TTA nurse did not check the patient’s blood sugar level.
• In case 57, the patient was experiencing back pain and had an
abnormally elevated blood pressure; however, the TTA nurse
did not perform a back and musculoskeletal assessment prior to
discharging the patient.
Nursing Documentation
Complete and accurate documentation illustrates the quality and
timeliness of emergency care. COR nurses continued to have difficulty
documenting the proper sequence of events and pertinent information,
such as care provided and medications administered during an
emergency. These deficiencies occurred in nine cases.19 Examples
included the following cases:
• In case 6, the first medical responder documented oxygen was
delivered via a nonrebreather mask on the patient, who was
not breathing. Additionally, the first medical responder did not
document the naloxone doses administered to the patient on the
medication administration record (MAR).
• In case 7, after the patient expired, the nurses documented
incorrectly the times naloxone was administered to the patient
on the MAR.
Emergency Medical Response Review Committee
Nursing supervisors and the EMRRC reviewed all emergency cases
within the required time frames. Of the nine emergency events
we reviewed that were also reviewed by the EMRRC and nursing
supervisors, we found reviewers usually recognized lapses in care and
implemented corrective actions to address the deficiencies.
Clinician On-Site Inspection
The TTA was appropriately equipped and well-staffed with two nurses
at all times to handle emergency events. A provider was assigned in the
TTA during business hours, and an on-call provider was available after
hours and on weekends. Custody first responders actively participated
during medical emergencies, and other nurses assisted in the TTA when

18. Naloxone is a medication used to rapidly reverse opioid overdose.
19. Incomplete and inaccurate documentation occurred in cases 1, 2, 4, 5, 6, 7, 8, 18, and 55.

Report Issued: April 2021

Office of the Inspector General, State of California

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28

Cycle 6 Medical Inspection Report

needed. The institution partially completed staff training on the new
policy for emergency medical responses.

Recommendations
• Medical leadership should determine the root cause of
challenges with providers’ completion of progress notes
for emergent events and implement remedial measures as
appropriate to ensure they are completed.
• The EMRRC should identify and address delays in the transfer
of patients to a higher level of care, including delays due to
availability of custody staff.
• Nursing leadership should identify root causes that prevent
nurses from completely and accurately documenting assessments
and medication administration in emergent events and
implement remedial measures as appropriate.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

Health Information Management
In this indicator, OIG inspectors evaluated the flow of health
information, a crucial link in high-quality medical care delivery. Our
inspectors examined whether the institution retrieved and scanned
critical health information (progress notes, diagnostic reports, specialist
reports, and hospital-discharge reports) into the medical record in a
timely manner. Our inspectors also tested whether clinicians adequately
reviewed and endorsed those reports. In addition, our inspectors
checked whether staff labeled and organized documents in the medical
record correctly.

Results Overview

29

Overall
Rating

Adequate
Case Review
Rating
Adequate
Compliance
Score
Proficient
(89.9%)

Compared with Cycle 5, COR’s scores improved in compliance testing
for this indicator. COR’s strengths included obtaining hospital discharge
reports, scanning and labeling medical records, and reviewing pathology
results. The institution had room for improvement in obtaining,
scanning, and reviewing specialty reports within the required time
frames. Factoring compliance scoring and case reviews, we rated this
indicator adequate.

Case Review Results
We reviewed 958 events and found 55 deficiencies related to health
information management. Of these 55 deficiencies, six were significant.20
Hospital-Discharge Reports
COR managed hospital records well. Staff retrieved and scanned hospital
discharge records within required time frames (MIT 4.003, 95.0%). The
institution frequently ensured discharge records included discharge
summaries, and the primary care provider reviewed the records within
five calendar days of the patient’s discharge (MIT 4.005, 88.0%). OIG
case review clinicians reviewed 22 off-site emergency department and
hospital events and found one minor deficiency with the retrieval of the
discharge summary:
• In case 5, the patient was evaluated for a drug overdose in the
emergency department. The complete discharge summary
was not obtained and scanned into the patient’s electronic
medical record.
Specialty Reports
Compliance testing showed poor performance in scanning specialty
reports within required time frames (MIT 4.002, 66.7%). OIG clinicians

20. Deficiencies occurred in cases 1, 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 50,
51, 54, 55, 56, and 57. Significant deficiencies occurred in cases 12, 14, 16, 18, 19, and 57.

Report Issued: April 2021

Office of the Inspector General, State of California

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30

Cycle 6 Medical Inspection Report

identified deficiencies in retrieving and scanning dictated specialty
reports in six cases, including the following two cases:21
• In case 14, the patient underwent cataract surgery with the
ophthalmology specialist; however, the surgical report for the
patient was not obtained or scanned.
• In case 51, the patient saw the neurosurgeon specialist.
The specialty report was not retrieved until six days after
the appointment.
In compliance testing, COR had variable performance in retrieving
specialty reports and reviewing high-priority specialty reports (MIT
14.002, 80.0%), medium-priority specialty reports (MIT 14.005, 46.7%) and
routine-priority specialty reports (MIT 14.008, 64.3%). Our case review
clinicians found COR providers endorsed specialty reports outside the
required time frames in case 21, and the two cases below.
• In case 8, the patient had surgery on his right eye. The provider
did not endorse the patient’s specialty report until seven days
after it was retrieved.
• In case 55, the patient had an appointment with the off-site
urologist; however, the provider endorsed the urology specialty
report five days after it was received.
The Specialty Services indicator has additional details regarding COR’s
specialty performance.
Diagnostic Reports
Compliance testing showed COR providers performed well in endorsing
pathology results (MIT 2.011, 100%). However, the providers did not send
result letters to patients within the required time frames (MIT 2.012,
zero). Further analysis of these compliance samples revealed providers
did not send result letters to their patients but did discuss pathology
results with their patients at subsequent appointments. This correlated
with the findings of our case review clinicians.
Compliance testing did not have applicable samples to evaluate the
management of STAT laboratory test results by the nurse and provider
(MIT 2.008, N/A). Case review clinicians did not find any deficiencies in
the handling of STAT laboratory test results. Please see the Diagnostic
Services indicator for more details.
Urgent and Emergent Records
OIG clinicians reviewed 55 emergency care events and found the events
were generally documented. We found providers had some lapses in fully
documenting their emergency care. The Emergency Services indicator
has additional information regarding emergency care documentation.

21. Deficiencies occurred in cases 8, 10, 14, 16, 19, and 51.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

31

Scanning Performance
COR scored well in scanning health care request forms into patients’
electronic health records (MIT 4.001, 100%). Furthermore, compliance
testing showed excellent performance in properly scanning, labeling,
and including the correct patient file in the medical records (MIT 4.004,
100%). Our clinicians found minor deficiencies in misfiled, mislabeled, or
misdated medical records in cases 8, 57, and the following two cases:
• In case 15, the patient had an electrocardiogram (EKG), but it was
scanned late and misfiled on the wrong date.
• In case 22, the patient’s refusal form was incorrectly labeled as
discharge instructions in the electronic health record (EHRS).
Clinician On-Site Inspection
We interviewed health information management supervisors, providers,
utilization management nurses, and staff regarding our case review
questions and health information processes. The supervisor discussed
recent workflows to improve health information management, including
holding meetings with a local laboratory to improve communication of
laboratory results. COR laboratory staff use a tracker to follow up with
results and providers’ reviews. Utilization management nurses also use a
tracker to ensure specialist and biopsy reports are retrieved timely. Some
staff members were provided access to local hospital medical records in
order to obtain reports easily.

Recommendations
• Medical leadership should determine the root cause of
challenges in timely scanning, retrieving, and reviewing specialty
service reports and implement remedial measures as appropriate
to ensure they are performed within required time frames.

Report Issued: April 2021

Office of the Inspector General, State of California

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32

Cycle 6 Medical Inspection Report

Compliance Testing Results
Table 9. Health Information Management
Scored Answer
Compliance Questions

Yes

No

N/A

Yes %

Are health care service request forms scanned into the patient’s
electronic health record within three calendar days of the encounter
date? (4.001)

40

0

0

Are specialty documents scanned into the patient’s electronic health
record within five calendar days of the encounter date? (4.002) *

20

10

15

66.7%

Are community hospital discharge documents scanned into the
patient’s electronic health record within three calendar days of
hospital discharge? (4.003) *

19

1

5

95.0%

During the inspection, were medical records properly scanned,
labeled, and included in the correct patients’ files? (4.004) *

24

0

0

For patients discharged from a community hospital: Did the
preliminary or final hospital discharge report include key elements
and did a provider review the report within five calendar days of
discharge? (4.005) *

22

3

0

100%

100%

88.0%

Overall percentage (MIT 4): 89.9%
* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.
Source: The Office of the Inspector General medical inspection results.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

33

Table 10. Other Tests Related to Health Information Management
Scored Answer
Compliance Questions

Yes

No

N/A

Yes %

Laboratory: Did the nursing staff notify the health care provider within
one (1) hour from receiving the STAT laboratory results? (2.008) *

N/A

N/A

N/A

N/A

Pathology: Did the health care provider review and endorse the
pathology report within specified time frames? (2.011) *

7

0

3

100%

Pathology: Did the health care provider communicate the results of the
pathology study to the patient within specified time frames? (2.012)

0

7

3

0

Did the institution receive and did the primary care provider review the
high-priority specialty service consultant report within the required time
frame? (14.002) *

12

3

0

80.0%

Did the institution receive and did the primary care provider review the
medium-priority specialty service consultant report within the required
time frame? (14.005) *

7

8

0

46.7%

Did the institution receive and did the primary care provider review the
routine-priority specialty service consultant report within the required
time frame? (14.008) *

9

5

1

64.3%

* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.
Source: The Office of the Inspector General medical inspection results.

Report Issued: April 2021

Office of the Inspector General, State of California

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34

Cycle 6 Medical Inspection Report

Overall
Rating

Inadequate
Case Review
Rating
(N/A)

Compliance
Score
Inadequate
(45.8%)

Health Care Environment
In this indicator, OIG compliance inspectors tested clinics’ waiting areas,
infection control, sanitation procedures, medical supplies, equipment
management, and examination rooms. Inspectors also tested clinics’
ability to maintain auditory and visual privacy for clinical encounters.
Compliance inspectors asked the institution’s health care administrators
to comment on their facility’s infrastructure and its ability to support
health care operations. The OIG rated this indicator solely on the
compliance score, using the same scoring thresholds as in the Cycle 4
and Cycle 5 medical inspections. Our case review clinicians do not rate
this indicator.

Compliance Testing Results
For this indicator, COR’s performance declined compared with
its performance in Cycle 5. Multiple aspects of COR’s health care
environment needed improvement: examination rooms lacked adequate
space; multiple clinics and the medical warehouse contained expired
medical supplies; emergency medical response bag (EMRB) logs were
missing staff verification; and staff did not regularly sanitize their
hands before or after examining patients. These factors resulted in an
inadequate rating for this indicator.
Outdoor Waiting Areas
We inspected the outdoor patient waiting areas at COR (see Photo 1,
below). There was a cooling sprinkler in the outdoor waiting areas

Photo 1. Outdoor waiting area (photographed on March 12, 2020).

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

35

Photo 2. Indoor waiting area (photographed on March 12, 2020).

for comfort in the hot weather. During
our inspection, we did not observe
any patients waiting outside for their
clinical appointments due to a fog alert.
Heath care and custody staff reported
the outdoor waiting areas had sufficient
seating capacity and provided patients
protection from inclement weather.
Indoor Waiting Areas
Inside the medical clinics, patients
had ample seating to wait for their
appointments (see Photo 2, above).
Depending on the population, patients
were either placed in the clinic waiting
area or held in individual modules (see
Photo 3, right) to wait for their medical
appointments. Waiting areas had
temperature control, running water,
toilets, and hand sanitation items. We
interviewed custody and medical staff,
who reported the patient waiting areas
were never at full capacity.

Report Issued: April 2021

Photo 3. Individual waiting module (photographed
on March 10, 2020).

Office of the Inspector General, State of California

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36

Cycle 6 Medical Inspection Report

Clinic Environment
Thirteen of the 14 clinic environments
were sufficiently conducive to medical
care; they provided reasonable
auditory privacy, appropriate waiting
areas, wheelchair accessibility, and
nonexamination-room workspace
(MIT 5.109, 92.9%). In one clinic,
the configuration of the vital check
stations did not provide auditory
privacy. Of the 11 clinics we observed,
only six contained appropriate
space, configuration, supplies, and
equipment to allow their clinicians to
perform proper clinical examinations
(MIT 5.110, 54.5%). The remaining
five clinics had one or more of
the following deficiencies: torn
examination table covers; examination
rooms measuring under 100 square
feet; and cluttered examination rooms.

Photos 4, above, and 5, right. Residual water damage
(photographed on March 12, 2020).

In addition to the above findings, our
compliance inspectors observed some
notable findings in clinics during their
on-site inspection. Several clinics had
ceilings with residual water damage,
for which staff provided us with
copies of work orders and submitted
repair requests (see Photos 4 and 5,
this page).
According to the nursing
administrative staff, the plant manager
denied their request because the clinic
swing spaces were only temporary and
construction of the new clinic spaces
was nearing completion.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

37

The plant manager reported staff
were busy completing other tasks at
COR to fulfill duties to the best of
their abilities.
Clinic Supplies
None of the 15 clinics followed
adequate medical supply storage
and management protocols
(MIT 5.107, zero).

Photo 6. Expired medical supply, dated June 2015
(photographed on March 12, 2020).

We found one or more of the
following deficiencies in all clinics
at COR: expired medical supplies
(see Photos 6, 7, and 8, this page);
unidentified medical supplies;
and compromised sterile medical
supplies packaging.

Photo 7. Expired medical supply, dated September 2019
(photographed on March 9, 2020).

We also found cleaning supplies
stored in the same area with
medical supplies; and staff’s
personal items and food stored in
the same area with medical supplies
(see Photo 9, page 38).

Photo 8. Expired medical supply, dated June 2019
(photographed on March 9, 2020).

Report Issued: April 2021

Office of the Inspector General, State of California

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38

Cycle 6 Medical Inspection Report

Five of the 15 clinics met requirements
for essential core medical equipment and
supplies (MIT 5.108, 33.3%). The remaining
ten clinics lacked medical supplies or had
improperly calibrated or nonfunctional
equipment. The missing items included a
nebulizer, tongue depressor, examination
table paper, hemoccult cards, lubricating
jelly, and biohazard bag or receptacle
bin. Among the improperly calibrated
or nonfunctional equipment, we found
Snellen charts that either had an
inaccurately identified distance line or did
not have an identified distance line on the
floor or wall, a nonfunctional otoscope,
an automatic external defibrillator (AED)
without a current calibration sticker, and
an expired lubricating jelly (see Photo 10,
below). We also noted staff did not
accurately log or failed to log the results of
the defibrillator performance test within
the preceding 30 days.

Photo 9. Staff members’ personal items and food stored
with medical supplies (photographed on March 12, 2020).

We examined EMRBs to determine
whether they contained all essential
items, and whether staff inspected the
bags daily and inventoried them monthly.
Only two of the 12 EMRBs passed our
test (MIT 5.111, 16.7%). We found one or
more of the following deficiencies with
10 EMRBs: staff failed to ensure the
EMRBs’ compartments were sealed and
intact, and staff had not inventoried the
EMRBs when the seal tags were replaced
nor inventoried the EMRBs in the previous
30 days. The crash carts in the correction
treatment center (CTC) contained several
expired medical supplies.
During our clinic inspections, we also
found multiple expired medical supplies
in the emergency stab bags. Stab bags

Office of the Inspector General, State of California

Photo 10. Expired lubricating jelly dated February 2020
(photographed on March 9, 2020).

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

39

are used with an EMRB when responding
to an emergency medical response. The
emergency stab bags were not organized or
regularly inventoried.
Medical Supply Management
None of the medical supply storage areas
located outside the medical clinics stored
medical supplies adequately (MIT 5.106, zero).
We found multiple expired medical supplies
(see Photos 11 and 12, right and below).
According to the chief executive officer
(CEO), the institution did not have any
concern about the medical supplies process.
Health care managers and medical warehouse
managers expressed no concerns about the
medical supply chain or their communication
process with the existing system.
Infection Control and Sanitation
Staff appropriately disinfected, cleaned, and
sanitized 11 of 15 clinics (MIT 5.101, 73.3%).
In four clinics, we found one or more of the
Photo 11. Expired medical supplies, dated January 31, 2020
(photographed on March 11, 2020).

following deficiencies: cleaning logs were not
maintained, accumulated dirt and grime on
examination room cabinets and a gurney, and
accumulated dust on an examination table.
Staff in six of 12 applicable clinics properly
sterilized or disinfected medical equipment
(MIT 5.102, 50.0%). In six other clinics,
we found one or more of the following
deficiencies: staff did not list disinfecting
the examination table as part of their daily
start-up protocol; staff did not regularly
log sterilized reusable medical equipment;
and compromised or no seals on sterilized
reusable medical equipment.

Photo 12. Expired medical supplies, dated February 29, 2020
(photographed on March 11, 2020).

Report Issued: April 2021

Office of the Inspector General, State of California

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Cycle 6 Medical Inspection Report

We found operating sinks and hand hygiene
supplies in the examination rooms in nine
of 14 applicable clinics (MIT 5.103, 64.3%). In
five clinics, patient restrooms either lacked
antiseptic soap or disposable hand towels or
sinks were nonfunctional for the health care staff
or patients, or both.
We observed patient encounters in nine clinics.
In six clinics, clinicians did not wash their hands
before or after examining their patients, before
applying gloves, or before performing blood
draw (MIT 5.104, 33.3%).
Health care staff in 12 of 14 applicable clinics
followed proper protocols to mitigate exposure
to blood-borne pathogens and contaminated
waste (MIT 5.105, 85.7%). In one clinic, we found
dried blood on and under two gurney mattresses
(see Photo 13, left). In another clinic, the
examination room lacked a sharps container.
Physical Infrastructure

Photo 13. Blood on the gurney mattress (photographed on
March 9, 2020).

The institution’s health care management and
plant operations manager reported all clinical
area infrastructures were in good working order
and construction of the medical clinic at COR
did not hinder health care services.

At the time of our medical inspection, the institution’s administrative team reported
eight concurrent ongoing health care facility improvement program (HCFIP)
construction projects. Some projects were still in the planning phase, while
others had already broken ground or were nearing completion. All eight projects
were for new medical clinic space. The institution reported multiple setbacks
relating to various obstacles causing delays in completion; three clinics were still
awaiting inspection approval from the fire marshal, and one clinic had a hot water
leak causing extensive damage. The administrative team offered no additional
information relating to future health care clinic space renovation plans (MIT 5.999).

Recommendations
Nursing leadership should consider performing random spot checks to ensure staff
follow equipment and medical supply management protocols.
• Medical leadership should remind staff to follow universal hand hygiene
precautions. Implementing random spot checks could improve compliance.
• Nursing leadership should have each clinic nurse supervisor review
the monthly EMRB logs to ensure the EMRBs are regularly inventoried
and sealed.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

41

Compliance Testing Results
Table 11. Health Care Environment
Scored Answer
Compliance Questions

Yes

No

Infection control: Are clinical health care areas appropriately
disinfected, cleaned, and sanitary? (5.101)

11

4

0

73.3%

Infection control: Do clinical health care areas ensure that reusable
invasive and noninvasive medical equipment is properly sterilized or
disinfected as warranted? (5.102)

6

6

3

50.0%

Infection control: Do clinical health care areas contain operable sinks
and sufficient quantities of hygiene supplies? (5.103)

9

5

1

64.3%

Infection control: Does clinical health care staff adhere to universal
hand hygiene precautions? (5.104)

3

6

6

33.3%

Infection control: Do clinical health care areas control exposure to
blood-borne pathogens and contaminated waste? (5.105)

12

2

1

85.7%

Warehouse, conex, and other nonclinic storage areas: Does the
medical supply management process adequately support the needs
of the medical health care program? (5.106)

0

1

0

0

Clinical areas: Does each clinic follow adequate protocols for
managing and storing bulk medical supplies? (5.107)

0

15

0

0

Clinical areas: Do clinic common areas and exam rooms have essential
core medical equipment and supplies? (5.108)

5

10

0

33.3%

13

1

1

92.9%

Clinical areas: Are the environments in the clinic exam rooms
conducive to providing medical services? (5.110)

6

5

4

54.5%

Clinical areas: Are emergency medical response bags and emergency
crash carts inspected and inventoried within required time frames,
and do they contain essential items? (5.111)

2

10

3

16.7%

Clinical areas: Are the environments in the common clinic areas
conducive to providing medical services? (5.109)

Does the institution’s health care management believe that all clinical
areas have physical plant infrastructures that are sufficient to provide
adequate health care services? (5.999)

N/A

Yes %

This is a nonscored test. Please
see the indicator for discussion of
this test.
Overall percentage (MIT 5): 45.8%

* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.
Source: The Office of the Inspector General medical inspection results.

Report Issued: April 2021

Office of the Inspector General, State of California

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Cycle 6 Medical Inspection Report

Overall
Rating

Inadequate
Case Review
Rating
Adequate
Compliance
Score
Inadequate
(51.2%)

Transfers
In this indicator, OIG inspectors examined the transfer process for
those patients who transferred into the institution, as well as for those
who transferred to other institutions. For newly arrived patients, our
inspectors assessed the quality of health screenings and the continuity
of provider appointments, specialist referrals, diagnostic tests, and
medications. For patients who transferred out of the institution,
inspectors checked whether staff reviewed patient medical records and
determined the patient’s need for medical holds. They also assessed if
staff transferred patients with their medical equipment and gave correct
medications before patients left. In addition, our inspectors evaluated the
ability of staff to communicate vital health transfer information, such as
preexisting health conditions, pending appointments, tests, and specialty
referrals; and inspectors confirmed if staff sent complete medication
transfer packages to the receiving institution. For patients who returned
from off-site hospitals or emergency rooms, inspectors reviewed whether
staff appropriately implemented the recommended treatment plans,
administered necessary medications, and scheduled appropriate followup appointments.

Results Overview
Similar to Cycle 5, COR performed poorly in completing initial health
screening forms, timely receiving previously ordered medications
for patients transferring into COR from other institutions, and
completing transfer packets for patients transferring from COR to other
institutions. Additionally, we found delayed access to approved specialty
appointments for newly arrived patients and lapses in medication
continuity for patients returning from the hospital. The institution did
improve access to the primary care team for newly arrived patients, as
well as retrieval, scanning, and provider review of hospital discharge
reports. Factoring both compliance and case reviews, we rated this
indicator inadequate.

Case Review Results
Our clinicians reviewed 24 cases in which patients transferred into or
out of the institution or returned from an off-site hospital or emergency
room, and identified 16 deficiencies, four of which were significant.22 In
most cases, COR ensured medical care continued during transfers. There
were some lapses, particularly in medication management, but none
adversely affected patient care.
Transfers In
We reviewed eight patients who transferred into COR from another
institution. The R&R nurses completed initial health screenings of
22. Deficiencies occurred in cases 1, 4, 5, 8, 9, 17, 24, 28, 50, 51, 52, and 55. Cases 51 and 55
had significant deficiencies.

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43

patients upon arrival to the institution. However, compliance testing
found R&R nurses scored poorly in completing initial health screening
(MIT 6.001, zero). All screenings missed one or more pertinent item of
information, such as symptoms in tuberculosis (TB) screening and vital
signs within the required time frame.23
Nurse or provider referrals for newly arriving patients occurred within
the specified time frames. We found only one case where the R&R nurse
did not refer a patient, who returned from a mental health placement,
to the RN care manager.24 Compliance testing also showed R&R nurses
completed the disposition section of the initial health screening
form in 23 of the 24 samples tested (MIT 6.002, 95.8%) and provider
appointments for newly arriving patients occurred timely for 20 of the
25 samples tested (MIT 1.002, 80.0%). Our case review clinicians found
R&R nurses evaluated newly arriving patients timely and performed
adequate assessments.
COR performed poorly in ensuring approved specialty appointments
for newly arriving patients occurred within the required time frames
(MIT 14.010, 65.0%), with appointment delays from 21 to 49 days. Our
case review clinicians reviewed two patients transferring into COR with
approved specialty appointments and did not identify any lapses.
Compliance testing found low scores in medication continuity for
patients transferred into COR (MIT 6.003, 58.8%), reassigned to another
yard within the institution (MIT 7.005, 64.0%), and patients en route
to another institution (MIT 7.006, 40.0%). Patients received their
medications either late or not at all. We identified delays in medication
administration in two of the transfer-in cases we reviewed.25 The nurses
documented medication in the sending institution encounter in three
cases,26 and in two cases the patient refused medication. Our clinicians
found COR did not ensure medication continuity in one out of the five
cases reviewed:
• In case 24, the patient transferred into COR from another
institution and did not receive his eye drops or intestinal
medication for two days.
COR provided adequate provider follow-up for patients transferring into
the institution (MIT 1.002, 80.0%). However, compliance testing found
poor performance in scheduling specialty appointments for patients who
transferred into COR with preapproved specialty appointments (MIT
14.010, 65.0%). Our case review clinicians did not identify any missed or
delayed preapproved specialty referrals.

23. In April 2020, CCHCS reported having added the symptom of fatigue into the EHRS for
TB symptom monitoring.
24. Case 24.
25. Delays in medication administration occurred in cases 24 and 52.
26. This occurred in cases 9, 17, and 24.

Report Issued: April 2021

Office of the Inspector General, State of California

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Cycle 6 Medical Inspection Report

Transfers Out
Our clinicians reviewed eight patients who transferred out of COR
into other institutions and identified three deficiencies, one of which
was significant.27 R&R nurses performed face-to-face evaluations, sent
required transfer documents, and administered prescribed medications
when patients transferred. However, the nurses sometimes did not
inform the receiving institution of the patient’s pending appointments,
tests, and specialty referrals or send prescribed medications with the
patients. These deficiencies are illustrated in the cases below:
• In case 1, the R&R nurse did not communicate the status of the
patient’s hepatitis C treatment.
• In case 28, the nurse did not send all medications with the
patient.
• In case 51, the nurse did not communicate the patient’s
recommended specialty follow-up appointment and diagnostic
tests to the receiving institution and did not document whether
prescribed medications were sent with the patient.
Our regional compliance inspectors also confirmed only four of the eight
transfer packets they reviewed on-site had the required medications
(MIT 6.101, 50.0%).
Hospitalizations
Patients returning from an off-site hospitalization or emergency
room are at high risk for lapses in care. These patients have typically
experienced severe illness or injury. They require more care and place
strain on the institution’s resources. Because these patients have complex
medical issues, the successful transfer of health information is necessary
for quality care. Any lapse of care can result in serious consequences for
these patients.
Our clinicians reviewed 21 hospital or emergency room returns in
13 cases28 and found TTA nurses properly evaluated patients upon
return from the hospital or emergency department. The nurses
reviewed hospital discharge reports, informed the provider of hospital
recommendations, and scheduled provider follow-up appointments. Our
case review clinicians identified eight deficiencies, three of which were
significant.29 Although providers thoroughly reviewed hospital discharge
summaries, they sometimes missed hospital recommendations as in the
following cases:
• In case 4, the hospital discharge summary recommended
diagnostic tests to follow up on the patient’s abnormal diagnostic
results; however, the provider did not order the tests.
27. Transfers-out occurred in cases 1, 26, 27, 28, 51, 53, 54, and 55. Deficiencies occurred in
cases 1, 28, and 51. A significant deficiency occurred in case 51.
28. Hospital/ED return cases: 1, 2, 4, 5, 8, 17 ,18, 19, 20, 21, 50, 51, and 55.
29. Deficiencies occurred in cases 4, 5, 8, 50, and 55. All significant deficiencies occurred in
case 55.

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45

• In case 55, the hospital discharge summary recommended
the patient receive an antibiotic medication as treatment for
infection, but the provider did not order the medication.
Compliance testing revealed a low score in the continuity of hospitalrecommended medications (MIT 7.003, 40.0%). When we reviewed these
compliance samples we found most medications were not available
from one to three days. Some of these medications were antibiotics and
inhalers. Our case review clinicians found delayed delivery of medication
in two cases.30
Provider follow up after hospital or emergency room return occurred
most of the time (MIT 1.007, 78.3%). Hospital discharge summary
or emergency room reports were also available (MIT 4.003, 95.0%),
complete, and reviewed by providers timely (MIT 4.005, 88.0%). Our
case review clinicians found a few hospital reports dated and scanned
incorrectly or incompletely.31
Clinician On-Site Inspection
Patients arriving to or departing from the institution, en route to another
institution, or returning from court appointments were evaluated in the
R&R. The R&R clinic had ample space to interview and examine patients
privately. An R&R nurse was assigned at all times during the week, and
a clerical staff member assisted during business hours. We interviewed a
second watch nurse, who was newly hired as the R&R nurse. The nurse
was very knowledgeable and familiar with the transfer processes. On
average, COR processed 60 to 100 incoming and outgoing transfers
weekly. The nurse reported COR had temporarily ceased transfers in and
out of the institution, unless necessary, due to the COVID-19 pandemic.
The TTA nurses evaluated patients returning from the hospital or mental
health crisis bed units located outside of the institution.

Recommendations
• Nursing leadership should determine the cause of challenges
in providing medications to newly arriving patients without
interruption and implement remedial measures as appropriate.
• The department should consider developing and implementing
an electronic alert to ensure nurses in receiving and release
(R&R) properly complete initial health screening questions and
follow up as needed.

30. Deficiencies occurred in cases 8 and 55.
31. Deficiencies in cases 5 and 8.

Report Issued: April 2021

Office of the Inspector General, State of California

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46

Cycle 6 Medical Inspection Report

Compliance Testing Results
Compliance On-Site Inspection
Our compliance inspectors found the transfer-out process at COR
lacked acceptable elements resulting in several deficiencies. We tested
eight patients transferring out of COR to other institutions. COR
nursing staff performed face-to-face evaluations before patients were
transferred out of the institution. During our on-site inspection, we
identified improvement opportunities in this area. COR nurses did not
consistently document pertinent information of patients’ current list
of missing medications or missing durable medical equipment. The
nursing staff also did not ensure each patient transferred with all proper
durable medical equipment, or keep-on-person and rescue medications.
In addition, nursing staff included insufficient quantities of California
Penal Code section 2602 ordered medications32 in patients’ transfer
envelopes upon departure to another institution.

Table 12. Transfers

Scored Answer
Yes

No

0

25

0

For endorsed patients received from another CDCR institution or
COCF: When required, did the RN complete the assessment and
disposition section of the initial health screening form; refer the
patient to the TTA if TB signs and symptoms were present; and
sign and date the form on the same day staff completed the health
screening? (6.002)

23

1

1

95.8%

For endorsed patients received from another CDCR institution or
COCF: If the patient had an existing medication order upon arrival,
were medications administered or delivered without interruption?
(6.003) *

10

7

8

58.8%

4

4

2

50.0%

Compliance Questions
For endorsed patients received from another CDCR institution or
COCF: Did nursing staff complete the initial health screening and
answer all screening questions within the required time frame?
(6.001) *

For patients transferred out of the facility: Do medication transfer
packages include required medications along with the corresponding
transfer packet required documents? (6.101) *

N/A

Yes %

0

Overall percentage (MIT 6): 51.2%
* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.
Source: The Office of the Inspector General medical inspection results.

32. These consist of psychotropic medications involuntarily administered to patients with
mental disorders.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

Table 13. Other Tests Related to Transfers

47

Scored Answer

Compliance Questions

Yes

No

N/A

Yes %

For endorsed patients received from another CDCR institution: Based on
the patient’s clinical risk level during the initial health screening, was the
patient seen by the clinician within the required time frame? (1.002) *

20

5

0

80.0%

Upon the patient’s discharge from the community hospital: Did the
patient receive a follow-up appointment with a primary care provider
within the required time frame? (1.007) *

18

5

2

78.3%

Are community hospital discharge documents scanned into the
patient’s electronic health record within three calendar days of hospital
discharge? (4.003) *

19

1

5

95.0%

For patients discharged from a community hospital: Did the preliminary
or final hospital discharge report include key elements and did a
provider review the report within five calendar days of discharge?
(4.005) *

22

3

0

88.0%

Upon the patient’s discharge from a community hospital: Were all
ordered medications administered, made available, or delivered to the
patient within required time frames? (7.003) *

10

15

0

40.0%

Upon the patient’s transfer from one housing unit to another: Were
medications continued without interruption? (7.005) *

16

9

0

64.0%

For patients en route who lay over at the institution: If the temporarily
housed patient had an existing medication order, were medications
administered or delivered without interruption? (7.006) *

4

6

0

40.0%

For endorsed patients received from another CDCR institution: If
the patient was approved for a specialty services appointment at the
sending institution, was the appointment scheduled at the receiving
institution within the required time frames? (14.010) *

13

7

0

65.0%

* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.
Source: The Office of the Inspector General medical inspection results.

Report Issued: April 2021

Office of the Inspector General, State of California

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48

Cycle 6 Medical Inspection Report

Overall
Rating

Inadequate
Case Review
Rating
Inadequate
Compliance
Score
Inadequate
(51.4%)

Medication Management
In this indicator, OIG inspectors evaluated the institution’s ability to
administer prescription medications on time and without interruption.
The inspectors examined this process from the time a provider
prescribed medication until the nurse administered the medication to
the patient. When rating this indicator, the OIG strongly considered
the compliance test results, which tested medication processes to a
much greater degree than case review testing. In addition to examining
medication administration, our compliance inspectors also tested many
other processes, including medication handling, storage, error reporting,
and other pharmacy processes.

Results Overview
COR performed poorly in medication management in both compliance
testing and case review. Compliance testing results showed low scores
in chronic medication continuity, hospital discharge medications, and
medication in specialized medical housing. Our compliance testing
illustrated a more robust assessment of the institution’s poor medication
administration practices and pharmacy protocols. We also identified
more deficiencies in our case reviews than during Cycle 5. After
considering all factors, we rated this indicator inadequate.

Case Review Results
We reviewed 121 events related to medications and found 33 deficiencies,
four of which were significant.33
New Medication Prescriptions
The nurses did not always administer new medications on time. In
most cases, the medication was not available on the date the provider
had ordered.34 Compliance testing also showed 68.0 percent of patients
received their newly ordered medications within specified time frames
(MIT 7.002), which was a decline from the previous Cycle 5 compliance
score. Further review of the compliance samples revealed five patients
did not receive their medication on time. Also, an additional three
patients refused their medication, and the nurses did not document
the refusals.
Chronic Care Medication Continuity
Our case review clinicians found patterns of minor delays in the
availability of chronic medications and intermittent gaps in medication
administration.35 Compliance testing revealed patients often did not
33. Deficiencies occurred in cases 2, 8, 9, 12, 13, 14, 15, 16, 18, 22, 24, 28, 51, 52, 53, 55, and 57.
Significant deficiencies occurred in cases 2, 9, 12, and 55.
34. Deficiencies occurred in cases 8, 16, 22, 24, 53, and 57.
35. These deficiencies occurred in more than once in cases 9, 13, 15, 16, 18, and once in
cases 2, 51, and 57.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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49

receive their chronic medications as scheduled (MIT 7.001, 10.5%). These
delays were generally related to policy compliance and not clinically
significant. Our clinicians identified 26 deficiencies of chronic care
medication not being administered as prescribed.36 The following cases
illustrate these deficiencies:
• In case 2, during September 2019, the patient did not receive his
keep-on-person (KOP) chronic medications timely. There was a
delay of more than five days.
• In case 12, the patient’s medication had expired and was not
renewed. Therefore, the patient never received the medication.
• In case 9, from November 6, 2019 to November 9, 2019, the
medication nurse did not follow the primary care provider’s
order and administered inaccurate doses of regular insulin.
Furthermore, the nurse incorrectly recorded the doses of insulin
administered throughout the month. The documentation showed
the patient received very small amounts of insulin, less than what
was ordered.
Hospital Discharge Medications
Compliance testing sampled 25 patients, who returned from the
hospital with prescribed medications, and found poor performance
(MIT 7.003, 40.0%). The patients either received their medications late,
or there was no record of the patients receiving their medications. For
one patient, who had a recommendation to receive an antibiotic for
10 days, the medication was never ordered and why the antibiotic had
not been ordered was not documented.37 This is also discussed in the
Transfers indicator.
Specialized Medical Housing Medications
Patients in the specialized housing units usually received their prescribed
medications without delay. Our clinicians found occurrences of patients
not receiving medications or receiving prescribed medications late, and
in one instance we found involved a provider who did not continue one
patient’s chronic medication when it expired.38 Although compliance
testing showed medication delays (MIT 13.004, 50.0%), the delays were
not clinically significant.

36. Deficient cases occurred in case 2, 9, 12, 13, 14, 15, 16, 50, 51, 52, 53, 55, 57. Significant
deficiencies occurred in case 2, 9, and 12.
37. This deficiency occurred in case 55.
38. These deficiencies occurred in cases 12, 51, and 53.

Report Issued: April 2021

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Cycle 6 Medical Inspection Report

Transfer Medications
COR had room for improvement with transfer medications. Compliance
testing showed some delays in medication administration for patients
arriving into the institution(MIT 6.003, 58.8%). We also identified two
deficiencies in our case review.39 Medication continuity for patients
transferring from one housing unit to another within the institution
scored at 64.0 percent (MIT 7.005). However, only two patients we
tested did not receive their medications. Most patients refused their
medications, and the nurses did not document the reason for their
refusals. Our case review clinicians did not review any cases for transfers
within COR. Compliance testing found low medication continuity for
patients en route to another institution (MIT 7.006, 40.0%).
COR did not always send required medications for patients transferring
out of the institution and received a low compliance rate of 50.0 percent
(MIT 6.101). Our clinicians found one case where medications were
delayed for one day.40
Medication Administration
The nurses generally administered medications on time. In a few
occurrences, the nurses did not administer medications because
they were not available. Our compliance inspectors tested how COR
nurses administered and monitored patients taking tuberculosis (TB)
medications and found good TB medication continuity (MIT 9.001,
84.6%) but poor TB monitoring (MIT 9.002, zero). We identified
significant deficiencies of insulin administration in the case below:
• In case 9, the patient had diabetes and received insulin
medications. The provider prescribed regular insulin on a sliding
scale therapy and Tresiba.41 The nurses administered incorrect
doses of insulin, administered medications when not indicated or
without checking blood sugar level, and withheld an insulin dose
without notifying the provider. These errors could have adversely
affected the patient. The nurses also erroneously recorded the
amount of insulin administered several times, thus it appeared
the patient received the wrong dose.
Clinician On-Site Inspection
Nurse leadership reported having sufficient medication nurses assigned
in each clinic. The nurses usually attend morning huddles and inform the
care team of any medication issues. The nurses articulated medication

39. These deficiencies occurred in cases 24 and 52.
40. Deficiency in case 52.
41. Insulin is a medication to treat high blood glucose. Regular insulin is a short-acting
insulin that starts to work approximately within 30 minutes of administration. A sliding
scale therapy is an administration of a prescribed dose based on the blood sugar level of the
patient. This requires the nurse to obtain the patient’s blood glucose reading and select the
proper dose based on the result. Tresiba is a long-acting insulin that helps control blood
sugar throughout the day.

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Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

51

administration practices for transfers, hospital returns, medication
noncompliance, and KOP medications.
COR had recently hired a new pharmacist. COR’s current process
for KOP medications includes delivering them two days prior to the
medication due date. COR also has implemented stock medications for
the 150 most commonly prescribed medications, including both nurse
administered and direct observed therapy medications, in 25 locations.

Compliance Testing Results
Medication Practices and Storage Controls
The institution adequately stored and secured narcotic medications in
all applicable clinic and medication line locations (MIT 7.101, 100%).
COR appropriately stored and secured nonnarcotic medications in
nine of 14 clinic and medication line locations (MIT 7.102, 64.3%). In
five locations, we identified one or more of the following deficiencies:
crash cart logs missing daily security check entries or having
inaccurate security check entries; no clearly identifiable designated
area for medications to be returned to the pharmacy; and disorganized
medication storage.
Staff kept medications protected from physical, chemical, and
temperature contamination in seven of the 14 clinic and medication
line locations (MIT 7.103, 50.0%). In seven locations, we found one or
more of the following deficiencies: staff did not store oral and topical
medications separately; staff did not consistently record the room
and refrigerator temperatures; logs indicated medications were not
stored within acceptable temperature range; accumulated grime on the
medication refrigerator; and staff stored medications with disinfectant.
Staff successfully stored valid unexpired medications in ten of the
14 applicable clinic and medication line locations (MIT 7.104, 71.4%).
In four locations, we found one or more of the following deficiencies:
medication nurses did not label the multiple-use medication; inhalation
solutions were not stored within the manufacturers’ guidelines; and
medication was stored beyond the expiration date.
Nurses exercised proper hand hygiene and contamination control
protocols in four of seven applicable locations (MIT 7.105, 57.1%). In three
locations, some nurses neglected to wash or sanitize their hands before
donning gloves or before each subsequent regloving.
In four of seven medication preparation and administration areas, staff
demonstrated appropriate administrative controls and protocols (MIT
7.106, 57.1%). In three locations, nurses did not maintain nonissued
medication in its original labeled packaging.
In three of seven medication areas, staff used appropriate administrative
controls and protocols when distributing medications to their patients
(MIT 7.107, 42.9%). In four locations, medication nurses did not reliably

Report Issued: April 2021

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52

Cycle 6 Medical Inspection Report

observe patients while they swallowed direct observation therapy
medications or did not appropriately administer medication as ordered
by the provider, or both.
According to nursing administration, COR utilizes only one specific
glucometer model for patient care, the Assure Platinum Meter which
self-calibrates. However, during our inspection we found additional
glucometer models in several clinic areas, which nursing staff reported
using as back-ups. In multiple locations, we interviewed medication
administration nurses, who were unable to describe circumstances when
a glucometer should be control tested. The nurses reported glucometer
control testing occurred rarely or never at all, which was corroborated by
our finding during our on-site inspection. In some locations, we found
incomplete quality control logs, while in other locations, we found no
logs at all. The logs we reviewed included inconsistent data and data
reflecting uncalibrated glucometers. We did not find any remedial
measures taken to fix the uncalibrated glucometers. The nursing staff
reported that even with abnormal control readings, insulin medications
for multiple patients continued to be regularly administered daily.
We also found multiple medication prescriptions with expired labels
for specific patients that nursing staff continued to administer to
these patients. The nursing staff did not consistently request updated
medication labels for new medications from the pharmacy when needed.
Pharmacy Protocols
Pharmacy staff followed general security, organization, and cleanliness
management protocols in the institution’s main and remote pharmacies
(MIT 7.108, 100%).
In its main pharmacy, staff did not properly store nonrefrigerated
medications. We found expired medications stored in the pharmacy.
Additionally, staff stored bulk food items within the medication
preparation area. As a result, COR scored zero for this test (MIT 7.109).
The institution properly stored refrigerated or frozen medications in the
pharmacy (MIT 7.110, 100%).
The pharmacist in charge (PIC) did not correctly review monthly
inventories of controlled substances in the institution’s clinic and
medication storage locations. Specifically, the PIC did not correctly
complete several medication area inspection checklists (CDCR Form
7477). These errors resulted in a score of zero in this test (MIT 7.111).
We examined 24 medication error reports. The PIC timely and correctly
processed only two of these 24 reports (MIT 7.112, 8.3%). For 22 reports,
one or more of the following deficiencies were identified: the PIC did not
complete the pharmacy follow-up review form within the three business
days from the error’s reported date; the form was missing pertinent
data related to the error, including documentation of medication error
notification to the patient or prescribing physician, determinations or
findings; and recommended changes to correct the medication error.

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Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

53

Nonscored Tests
In addition to testing the institution’s self-reported medication errors,
our inspectors also followed up on any significant medication errors
found during compliance testing. We do not score this test; we provide
these results for informational purposes only. We did not find any
applicable medication errors for COR (MIT 7.998).
The OIG interviewed patients in isolation units to determine whether
they had immediate access to their prescribed rescue medications.
Sixteen of 17 applicable patients interviewed indicated they had access
to their rescue medications. One patient reported he finished his
medication a few days prior and had requested a refill. We promptly
notified the CEO of this concern, and health care management
immediately reissued a replacement rescue inhaler to the patient
(MIT 7.999).

Recommendations
• Medical leadership should determine the cause of challenges
related to medication continuity for chronic care, transferin, hospital discharge, and en route patients and implement
remedial measures as appropriate.

Report Issued: April 2021

Office of the Inspector General, State of California

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54

Cycle 6 Medical Inspection Report

Table 14. Medication Management

Scored Answer
Yes

No

2

17

6

10.5%

Did health care staff administer, make available, or deliver new order
prescription medications to the patient within the required time frames? (7.002)

17

8

0

68.0%

Upon the patient’s discharge from a community hospital: Were all ordered
medications administered, made available, or delivered to the patient within
required time frames? (7.003) *

10

15

0

40.0%

For patients received from a county jail: Were all medications ordered by
the institution’s reception center provider administered, made available, or
delivered to the patient within the required time frames? (7.004) *

N/A

N/A

N/A

Upon the patient’s transfer from one housing unit to another: Were
medications continued without interruption? (7.005) *

16

9

0

64.0%

4

6

0

40.0%

13

0

2

All clinical and medication line storage areas for nonnarcotic medications:
Does the institution properly secure and store nonnarcotic medications in the
assigned storage areas? (7.102)

9

5

1

64.3%

All clinical and medication line storage areas for nonnarcotic medications:
Does the institution keep nonnarcotic medication storage locations free of
contamination in the assigned storage areas? (7.103)

7

7

1

50.0%

10

4

1

71.4%

Medication preparation and administration areas: Do nursing staff employ
and follow hand hygiene contamination control protocols during medication
preparation and medication administration processes? (7.105)

4

3

8

57.1%

Medication preparation and administration areas: Does the institution employ
appropriate administrative controls and protocols when preparing medications
for patients? (7.106)

4

3

8

57.1%

Medication preparation and administration areas: Does the institution employ
appropriate administrative controls and protocols when administering
medications to patients? (7.107)

3

4

8

42.9%

Pharmacy: Does the institution employ and follow general security,
organization, and cleanliness management protocols in its main and remote
pharmacies? (7.108)

1

0

0

100%

Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated
medications? (7.109)

0

1

0

0

Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen
medications? (7.110)

1

0

0

100%

Pharmacy: Does the institution’s pharmacy properly account for narcotic
medications? (7.111)

0

1

0

0

Pharmacy: Does the institution follow key medication error reporting
protocols? (7.112)

2

22

0

8.3%

Compliance Questions
Did the patient receive all chronic care medications within the required
time frames or did the institution follow departmental policy for refusals or
no‑shows? (7.001) *

For patients en route who lay over at the institution: If the temporarily housed
patient had an existing medication order, were medications administered or
delivered without interruption? (7.006) *
All clinical and medication line storage areas for narcotic medications: Does
the institution employ strong medication security controls over narcotic
medications assigned to its storage areas? (7.101)

All clinical and medication line storage areas for nonnarcotic medications: Does
the institution safely store nonnarcotic medications that have yet to expire in
the assigned storage areas? (7.104)

N/A

Yes %

N/A

100%

Pharmacy: For Information Purposes Only: During compliance testing, did the
OIG find that medication errors were properly identified and reported by the
institution? (7.998)

This is a nonscored test. Please see
the indicator for discussion of this
test.

Pharmacy: For Information Purposes Only: Do patients in isolation housing
units have immediate access to their KOP prescribed rescue inhalers and
nitroglycerin medications? (7.999)

This is a nonscored test. Please see
the indicator for discussion of this
test.
Overall percentage (MIT 7): 51.4%

* The OIG clinicians considered these compliance tests along with their case review findings when determining the
quality rating for this indicator.
Source: The Office of the Inspector General medical inspection results.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

55

Table 15. Other Tests Related to Medication Management
Scored Answer
Compliance Questions

Yes

No

N/A

Yes %

For endorsed patients received from another CDCR institution or COCF:
If the patient had an existing medication order upon arrival, were
medications administered or delivered without interruption? (6.003) *

10

7

8

58.8%

For patients transferred out of the facility: Do medication transfer
packages include required medications along with the corresponding
transfer-packet required documents? (6.101) *

4

4

2

50.0%

Patients prescribed TB medication: Did the institution administer the
medication to the patient as prescribed? (9.001) *

11

2

0

84.6%

Patients prescribed TB medication: Did the institution monitor the
patient per policy for the most recent three months he or she was on the
medication? (9.002) *

0

13

0

Upon the patient’s admission to specialized medical housing: Were all
medications ordered, made available, and administered to the patient
within required time frames? (13.004) *

5

5

0

0

50.0%

* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.
Source: The Office of the Inspector General medical inspection results.

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Office of the Inspector General, State of California

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Cycle 6 Medical Inspection Report

Overall
Rating

Inadequate
Case Review
Rating
(N/A)

Compliance
Score
Inadequate
(59.8%)

Preventive Services
In this indicator, OIG compliance inspectors tested whether the
institution offered or provided cancer screenings, tuberculosis
(TB) screenings, influenza vaccines, and other immunizations.
If the department designated the institution as high risk for
coccidioidomycosis (valley fever), we tested the institution’s ability to
transfer out patients quickly. The OIG rated this indicator solely based
on the compliance score, using the same scoring thresholds as in the
Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do
not rate this indicator.

Recommendations
• Medical leadership should remind nursing staff to perform
weekly monitoring and address the symptoms of patients taking
TB medications.

Table 16. Preventive Services

Scored Answer

Compliance Questions

Yes

No

N/A

Yes %

Patients prescribed TB medication: Did the institution administer the
medication to the patient as prescribed? (9.001)

11

2

0

Patients prescribed TB medication: Did the institution monitor the
patient per policy for the most recent three months he or she was on
the medication? (9.002)

0

13

0

0

Annual TB screening: Was the patient screened for TB within the last
year? (9.003)

0

25

0

0

Were all patients offered an influenza vaccination for the most recent
influenza season? (9.004)

25

0

0

100%

All patients from the age of 50 through the age of 75: Was the patient
offered colorectal cancer screening? (9.005)

22

3

0

Female patients from the age of 50 through the age of 74: Was the
patient offered a mammogram in compliance with policy? (9.006)

N/A

N/A

N/A

N/A

Female patients from the age of 21 through the age of 65: Was
patient offered a pap smear in compliance with policy? (9.007)

N/A

N/A

N/A

N/A

Are required immunizations being offered for chronic care patients?
(9.008)

12

2

11

85.7%

Are patients at the highest risk of coccidioidomycosis (valley fever)
infection transferred out of the facility in a timely manner? (9.009)

3

2

0

60.0%

84.6%

88.0%

Overall percentage (MIT 9): 59.8%
* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.
Source: The Office of the Inspector General medical inspection results.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

Nursing Performance
In this indicator, the OIG clinicians evaluated the quality of care
delivered by the institution’s nurses, including registered nurses (RNs),
licensed vocational nurses (LVNs), psychiatric technicians (PTs), and
certified nursing assistants (CNAs). Our clinicians evaluated nurses’
ability to make timely and appropriate assessments and interventions.
We also evaluated the institution’s nurses’ documentation for accuracy
and thoroughness. Clinicians reviewed nursing performance in many
clinical settings and processes, including sick call, outpatient care, care
coordination and management, emergency services, specialized medical
housing, hospitalizations, transfers, specialty services, and medication
management. The OIG assessed nursing care through case review only
and performed no compliance testing for this indicator.

57

Overall
Rating

Inadequate
Case Review
Rating
Inadequate
Compliance
Score
(N/A)

When summarizing overall nursing performance, our clinicians
understand that nurses perform numerous aspects of medical care. As
such, specific nursing quality issues are discussed in other indicators,
such as Emergency Services, Specialty Services, and Specialized
Medical Housing.

Results Overview
COR nurses delivered poor nursing care. Compared with Cycle 5,
we identified fewer nursing deficiencies; however, we noted more
significant opportunities for improvement in nursing performance.
Care management of high-risk diabetic patients, including medication
management, notification of abnormal results, and timely appointments
for symptomatic patients, placed patients at risk for delay of necessary
medical services. Nursing assessments and documentation remained
a challenge in emergency and outpatient care. Nurses did not always
inform providers of specialists’ recommendations, which contributed
to delayed or missed interventions. While these nursing deficiencies
illustrated poor performances, they can be improved with quality
improvement strategies. We considered the overall quality of nursing
care and rated this indicator inadequate.

Case Review Results
Our case review clinicians reviewed 302 nursing encounters in 56 cases.
Of the nursing encounters we reviewed, 136 were in the outpatient
setting. Most outpatient nursing encounters were for sick call requests
and nurse follow-up visits. We identified 88 nursing performance
deficiencies, 20 of which were significant.42
Nursing Assessment
All phases of the nursing process depend on the accurate and complete
collection of data. When incomplete data is documented, the overall
42. Significant deficiencies occurred in cases 2, 8, 9, 11, 14, 15, 19, 34, 51, 55, and 57.

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Office of the Inspector General, State of California

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Cycle 6 Medical Inspection Report

care of the patient could be affected, including incorrect diagnosis and
inappropriate treatment.
COR nurses generally performed appropriate assessments, including
patient interviews and physical examinations. However, nurses did
not always capture all components of focused assessments.43 We found
a few occurrences in which nurses did not obtain vital signs when
evaluating the patient or examine the patient’s body part related to the
medical complaint.44 During emergency care, nurses sometimes failed to
sufficiently examine the patient at the scene or evaluate the patient after
providing emergency treatment.45 We discuss these nursing deficiencies
in more detail in the specific indicators.
Nursing Intervention
Nursing interventions are actions nurses perform to provide safe and
effective patient care. Nurses can perform interventions independently,
use nursing protocols, or follow orders from the provider. Patient
outcome could be affected when nurses fail to intervene appropriately.
COR nurses neglected to properly intervene or follow provider orders
in 13 cases.46 Some nursing deficiencies resulted in delays or lapses in
care. Significant deficiencies are discussed in the Emergency Services,
Medication Management, Specialized Medical Housing, and Specialty
Services indicators. The following cases also illustrate the deficiencies
we found with nursing interventions:
• In case 9, the diabetic patient had significantly low and high
blood sugar levels on numerous occasions. During the fivemonth review period, medication nurses did not assess the
patient for signs and symptoms or notify the provider when
the patient’s blood sugar was either very low or very high.
Nurses also did not provide appropriate interventions, such
as administering correct insulin doses, providing the patient
glucose or snacks when his blood sugar was low, or rechecking
the patient’s blood sugar level. When the provider ordered blood
sugar checks, nurses failed to follow the provider’s order.
• In case 22, the patient had an infected wound. The clinic nurse
urgently (same day) referred the patient to the TTA but did not
communicate with the TTA nurse. As a result, the patient was
not seen in the TTA until the following day.
Nursing staff should improve communicating patient status, specialists’
recommendations, and hospital discharge instructions to other medical
staff and receiving institutions.47

43. These deficiencies occurred in cases 2, 8, 13, 16, 34, 45, 48, 49, and 57.
44. These deficiencies occurred in cases 9, 52, and 55.
45. These deficiencies occurred in cases 1, 2, 5, 8, 18, and 55.
46. These deficiencies occurred in cases 8, 9, 11, 14, 15, 18, 19, 22, 24, 34, 52, 55, and 57.
47. These deficiencies occurred in cases 1, 2, 8, 9, 14, 18, 22, 51, and 55.

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Nursing Documentation
Proper documentation enables the transmission of complete and
accurate information among health care staff, preventing lapses in care.
Inconsistent and incomplete nursing documentation at COR occurred
primarily during emergency events.48 In the outpatient clinics and
specialized medical housing units, there were occurrences of nurses not
recording care provided to patients, such as vital sign results, weight,
dietary intake, or wound description.49
Nursing Sick Call
The nursing sick call process involves reviewing each sick call request,
then determining whether the patient’s medical symptoms require
urgent or routine evaluation. We reviewed 98 sick call requests, 71 of
which resulted in face-to-face appointments with nurses. COR nurses
timely reviewed sick call requests and often made appropriate decisions.
However, in one case we found the nurse did not recognize the patient’s
symptoms as potentially urgent:
• In case 15, the diabetic patient complained of dizziness, nausea,
and vomiting on two separate sick call requests. Because these
symptoms could indicate significantly low or high blood sugar
levels, the nurse should have evaluated the patient the same day;
however, the patient was not evaluated until the following day.
We found nursing assessments generally lacked thoroughness50 and
occasionally failed to address the patient’s medical request.51
Care Management/ Coordination
Nurses had poor performance in chronic care management, including
caring for patients with diabetes. We found nursing care lacked
appropriate interventions for patients who presented with acute
symptoms or abnormally low blood sugars, specifically in reviewing
blood sugar readings of symptomatic patients and notifying providers of
patients with blood sugars which were abnormally low. The nurses did
not provide sufficient care coordination for high-risk diabetic patients.
• In case 9, the lapse of care coordination placed the patient
at increased risk of harm. The providers and nurses did not
manage the patient well as the patient had multiple emergency
evaluations for abnormal low and high sugar levels.

48. Incomplete and inconsistent documentations occurred in cases 1, 2, 4, 5, 6, 7, 8, 18, 53,
and 55).
49. These deficiencies occurred in cases 9, 18, 19, 31, 33, 40, 50, 52, 53, 55, and 56.
50. Incomplete assessments occurred in cases 2, 8, 13, 16, 31, 34, 45, 48, and 49.
51. The nurses did not address the patient’s medical requests in cases 1, 14, and 18.

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Wound Care
We reviewed five cases in which the nurses provided wound care52
and found one nurse missed a few wound care assessments and
documentation. Overall, COR nurses provided good wound care.
Emergency Services
While there were opportunities for improvement in nursing performance
and documentation, COR nurses provided adequate emergency care.
Specific details are provided in the Emergency Services indicator.
Transfers
R&R nurses conducted initial health screenings timely and referred
newly arriving patients to appropriate care team members within
the specified time frames. When patients transferred out of COR,
R&R nurses completed the transfer process but sometimes did not
communicate pertinent medical information to the receiving institution.
Additional details are provided in the Transfers indicator. Overall, the
R&R nurses provided satisfactory care.
Specialized Medical Housing
The correctional treatment center (CTC) and OHU nurses completed
timely assessments, provided essential care, and documented care
properly. We identified nursing intervention and documentation
deficiencies; however, they did not significantly affected patient
outcomes. More specific details are provided in the Specialized Medical
Housing indicator.
Specialty Services
COR nurses examined patients upon return from off-site specialty
appointments. We found nurses sometimes did not properly review
patients’ specialty reports or inform providers of specialists’
recommendations. This is detailed further in the Specialty
Services indicator.
Medication Management
Nurses administered most medications timely. However, we found
examples of poor insulin administration practices performed by nurses.
The Medication Management indicator provides further information.
Clinician On-Site Inspection
Clinic nurses attended well-prepared huddles. Morning huddles were
organized and ran smoothly. Most clinic staff actively participated
52. Cases 9, 10, 22, 53, and 56.

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in huddle discussions, which included essential information the care
team needed to provide patient care. Clinic staff were familiar with
clinic processes, such as nursing sick calls, care management and
coordination, and care team referrals. The new clinics were spacious and
clean. Protocol medications which nurses can administer in emergency
situations without provider orders were available for immediate
administration. Emergency equipment used by first medical responders
was easily accessible.
The chief nurse executive (CNE) was new to the position but had been
a nursing manager in COR for many years. The CNE and nursing
managers actively participated in our discussion and acknowledged the
nursing issues we identified during our case reviews. The line nurses
reported responding to emergency events in their area.
During our on-site visit we observed the institution’s response to
COVID-19. Most staff and patients were wearing face masks and
practicing social distancing when possible. Custody staff limited the
number of patients in the clinic to ensure social distancing. A month
before our on-site inspection, the Incident Command Post had been
activated. Nursing leadership also initiated a nursing command center
to monitor patients and provide guidance to staff. Nurses assigned to
the nursing command center tracked new cases, monitored patients
in isolation and patients quarantined throughout the institution,
and coordinated with the Incident Command Post to disseminate
information to all institutional staff. This dedicated system relieved
outpatient clinic staff of daily patient screenings and evaluations so
they could continue with their regular tasks. The nurse instructor,
public health nurses, and supervisors provided regular training on the
proper use of personal protective equipment and reminded nurses of
safety practices. Although we provide this information for context, we
did not assess the efficacy of COR’s nursing command center during
this inspection.

Recommendations
• Nursing leadership should consider implementing a performance
review to ensure nurses properly intervene when patients present
with acute medical symptoms and notify providers of abnormal
values timely.
• Nursing leadership should review the cause of lapses in chronic
care coordination for diabetic patients and implement remedial
measures as appropriate.
• Nursing leadership should determine the root cause of
challenges that prevent outpatient and special housing nurses
from performing complete assessments and documentation
of care accurately and implement remedial measures
as appropriate.

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Cycle 6 Medical Inspection Report

Overall
Rating

Inadequate
Case Review
Rating
Inadequate
Compliance
Score
(N/A)

Provider Performance
In this indicator, OIG case review clinicians evaluated the quality of
care the institution’s providers (physicians, physician assistants, and
nurse practitioners) delivered. Our clinicians assessed the institution’s
providers’ ability to evaluate, diagnose, and manage their patients
properly. We examined provider performance across several clinical
settings and programs, including sick call, emergency services,
outpatient care, chronic care, specialty services, intake, transfers,
hospitalizations, and specialized medical housing. The OIG assessed
provider care through case review only and performed no compliance
testing for this indicator.

Results Overview
COR provider performance was mixed. Providers usually assessed
appropriately, made good decisions, and ensured continuity of care in the
outpatient and specialized medical housing. However, providers faltered
in other areas. Compared with Cycle 5, there were more deficiencies in
this indicator during this medical inspection. Providers did not always
fully document their emergency medical care in the TTA, completely
review medical records including hospital and specialty records, or
consistently follow through with the specialists’ recommendations.
We also identified some lapses in diabetic management. These areas
can be improved with reminders and education. Taking all provider
performance into consideration, we rated this indicator inadequate.

Case Review Results
The OIG clinicians reviewed 148 provider encounters and identified
62 deficiencies related to provider performance, 14 of which were
significant.53 The clinicians performed 20 detailed physician case
reviews, of which 14 were adequate and six inadequate.
Assessment and Decision-Making
COR providers generally made good assessments and sound decisions.
Providers sufficiently addressed patients’ complaints, ordered correct
tests, and arranged appropriate follow-up appointments. Our clinicians
identified room for improvement in case 22 and the following case:
• In case 12, the provider evaluated the patient who was taking
opioids and sedative medications. The provider showed poor
decision making by not reevaluating the patient for chronic
opioid use when patient was sleepy during an exam. Additionally,
the provider did not assess the patient’s need for chronic opioid
usage during the review period.

53. Cycle 6 deficiencies occurred in cases 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23,
50, 51, 55, 56, and 57. Significant deficiencies occurred in cases 8, 9, 12, 19, 55, and 57.

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Review of Records
The review of records is an essential component of a provider’s
evaluation, and is especially important for patients who had recent
testing, saw a specialist, or returned from a higher level of care. Providers
must also review records for unfamiliar patients.
Our clinicians identified eight deficiencies involving review of
hospital discharge records, specialty reports, and the medication
administration record.54
The following cases illustrate the deficiencies identified:
• In case 4, the provider did not thoroughly review the patient’s
hospital discharge records and did not see the recommendation
to order a follow-up test for magnesium level. The provider did
not order the magnesium level test.
• In case 12, the provider did not review the medication
administration record carefully and did not see the patient’s
prescription for tamsulosin medication had expired. As a result,
the provider did not renew the medication. Two other providers
did not renew the medication while the patient was in the CTC.
Emergency Care
Providers were available for consultation with TTA nursing staff. We
identified 11 deficiencies,55 most of which were related to documentation
with a few related to decision making. Lapses in documentation can lead
to errors in communication, decision making, and care management. The
following cases illustrate opportunities for improvement:
• In case 9, the diabetic patient with a history of low and high
sugar fluctuations went to the TTA on three occasions. The
provider did not order a provider follow-up appointment within
five days for this high-risk patient.
• In case 18, the provider was consulted for a patient with
shortness of breath in the TTA. The provider did not document a
progress note.
• In case 55, in the TTA, the provider evaluated and cleared the
patient for admission to the mental health crisis bed, but did
not document a progress note. The provider did not address
the patient’s elevated heart rate before medically clearing the
patient. When the patient swallowed a razor blade, the provider
ordered X-rays to be completed three days later to check the
razor blade’s location, instead of the same day.
The Emergency Services indicator has additional discussion on
emergency care.

54. The deficiencies occurred in cases 4, 8, 10, 12, 19, 20, and 22.
55. Deficiencies occurred in cases 9, 18, 23, 55, and 57.

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Chronic Care
Providers gave appropriate care to patients with chronic medical
conditions such as hypertension, hepatitis C, and asthma. In case 55, the
provider did not address the patient’s high blood pressure.
However, case review clinicians found providers needed to improve with
diabetic management. Clinicians found five deficiencies in four cases
with diabetic care.56 The following cases illustrate these deficiencies:
• In case 9, the provider followed up with the diabetic patient
after recent TTA evaluations for a low sugar reading. Instead
of ordering a prompt follow-up to reassess the low sugar, the
provider ordered a follow-up in 30 days, putting the patient at
risk for another low sugar episode.
• In case 15, the provider evaluated the patient for a chronic care
appointment and noted the increased diabetic HgbA1c test level.
The provider did not adjust the patient’s diabetic medication to
lower rising sugar level or order a sooner appointment to closely
monitor the patient’s diabetes.
COR did not have any case review samples for anticoagulation management.
Specialty Services
The providers generally referred patients for specialty consultations
and followed up with the patients after the consultations. Our
clinicians found occurrences in which providers did not follow through
on specialists’ recommendations and did not arrange for follow-up
specialty appointments appropriately. The following cases illustrate
these deficiencies:
• In case 19, the urologist recommended X-rays to evaluate
for kidney stones for the patient. The provider reviewed the
recommendations, but did not order the X-rays.
• In case 8, the provider evaluated the patient and reviewed the
ophthalmologist’s eye drop medication recommendations. The
provider did not follow the specialist’s recommendations to
adjust the patient’s eye drop medication.
We discuss the providers’ specialty performance further in the Specialty
Services indicator.
Specialized Medical Housing
The providers delivered adequate care in the CTC. Our case review
clinicians found providers performed a written history and physical
examination for patients within the required time frames and delivered
clinically appropriate intervals. The deficiencies we identified were
mainly related to incomplete review of the medical records and

56. Deficiencies in diabetic care occurred in cases 9, 10, 11, and 15.

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documentation errors. Further details on the provider performance are
discussed in the Specialized Medical Housing indicator.
Documentation Quality
Our clinicians found many instances of insufficient provider
documentation in the case reviews. In nine cases, we identified
deficiencies in which lapses in documentation can affect patient care,
including emergency care, diagnoses, treatment, and specialty care.57 The
following cases show the poor documentation:
• In cases 9, 18, 23, 55, and 57, providers did not record TTA
progress notes.
• In case 8, the provider evaluated the patient after a hospital
discharge. The patient’s abdominal CT was abnormal and
showed fatty infiltration of the liver and a borderline large
spleen. However, the provider documented that the abdominal
CT was normal.
• In case 19, the provider documented for two months that the
patient’s urinary suprapubic catheter was draining even though
it was not functional.
Provider Continuity
COR maintained provider continuity in the outpatient and CTC settings.
Clinician On-Site Inspection
During our on-site inspection, we observed well organized morning
huddles attended by providers, supervisors, nurses, office technicians,
and medical assistants. During the huddles, the team discussed
appointment lines, specialty referrals, hospitalizations, medications, and
backlogs. We noticed staff practiced social distancing and used personal
protective equipment, such as face masks.
We met with chief medical executive (CME), chief physician and
surgeon (CP&S), and providers. According to the CME, COR’s provider
vacancy was 1.5 positions. COR’s eight providers included two
telemedicine physicians, two nurse practitioners, and one physician
assistant. The CME and CP&S review cases with the providers and
offer feedback throughout the year, as well as providing regular
performance evaluations.
COR providers generally expressed good morale and job satisfaction.
Providers noticed COVID-19’s impact on specialty services because
the off-site specialists closed practices and were not seeing patients.
During the previous three months, the providers have used e-consult, an
electronic specialty service, to help improve access to the specialists.

57. Deficiencies occurred in cases 8, 9, 16, 18, 19, 21, 23, 55, and 57.

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Recommendations
• Medical leadership should ascertain causative factors in the
timely provider review of hospital and specialty reports and with
provider follow through of recommendations. Medical leadership
should implement remedial measures as appropriate.

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Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

Specialized Medical Housing
In this indicator, OIG inspectors evaluated the quality of care in the
specialized medical housing units. We evaluated the performance of the
medical staff in assessing, monitoring, and intervening for medically
complex patients requiring close medical supervision. Our inspectors
also evaluated the timeliness and quality of provider and nursing intake
assessments and care plans. We considered staff members’ performance
in responding promptly when patients’ conditions deteriorated and
looked for good communication when staff consulted with one another
while providing continuity of care. At the time of our inspection, COR’s
specialized medical housing is an outpatient housing unit (OHU) and
correctional treatment center (CTC).

67

Overall
Rating

Adequate
Case Review
Rating
Adequate
Compliance
Score
Proficient
(85.0%)

Results Overview
COR providers and nurses delivered good care to their CTC and OHU
patients. Providers ensured timely admission history and physicals and
rounding on patients. Nurses performed routine patient assessments
and provided interventions appropriately. Compared with Cycle 5, COR
still has opportunities for improvement with wound and catheter care,
providers’ review of medical records, and administration of admission
medications within the required time frames. Overall, we rated this
indicator adequate.

Case Review Results
We reviewed four cases that occurred in the correctional treatment
center (CTC) and three cases that occurred in the outpatient housing
unit (OHU).58 We also evaluated the medical care of patients admitted
for short-term medical observations in the specialized medical housing
units.59 These cases included 62 provider events and 40 nursing events.
Because of the high care volume that occurs in specialized medical
housing units, each provider and nursing event represents up to one
month of provider care and one week of nursing care. We identified
26 deficiencies, seven of which were significant.60
Provider Performance
COR providers delivered adequate care in the cases we reviewed. We
found that providers performed well in completing admission history
and physical examinations for patients within the required time frames.
Compliance testing also showed good performance, with a score of
100 percent (MIT 13.002). We also noted providers checked on patients at
clinically appropriate intervals without any delays.

58. Deficiencies occurred in cases 9, 12, 18, 19, 20, 50, 51, 52, and 53.
59. Deficiencies occurred in cases 1, 9, 17, 18, and 20.
60. Deficiencies found in cases 9, 12, 18, 19, 20, 50, 51, 52, and 53. Significant deficiencies
found in cases 12 and 19.

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Cycle 6 Medical Inspection Report

The deficiencies we found with providers, primarily were related
to poor review of the medical records, not following through with
specialists’ recommendations, and documentation errors. We identified
12 deficiencies,61 six of which occurred in case 19. This case was not
representative of the overall provider care in the specialized medical
housing. The following are cases with identified deficiencies:
• In case 19, providers did not follow through with the urologist’s
recommendations, did not follow up on a urine test results,
and erroneously documented that a nonfunctioning catheter
was working.
• In case 50, the provider did not order the medication as
recommended in the hospital discharge report.
Nursing Performance
CTC nurses performed admission assessments on the day the patient
was admitted (MIT 13.001, 100%). Case review clinicians confirmed
nurses completed an initial assessment upon the patient’s admission in
all the CTC and OHU cases they reviewed. The CTC nurses regularly
checked on patients and generally provided good care. However, we did
find occurrences of incomplete assessment and documentation as well
as orders that were not carried out as requested. The following cases
illustrate these findings:
• In case 19, during the review period, the CTC nurses sometimes
did not document the color and description of the patient’s urine
or the gastric tube’s intake and residual amount.
• In case 52, the patient had an elevated blood pressure.
On another occasion, the patient complained of stomach
discomfort for several days. The OHU LVN did not inform
the RN or provider of these abnormalities to determine
appropriate interventions. Also, OHU nurses did not regularly
assess the patient’s condition or check his vital signs as the
provider ordered.
• In case 53, the patient had a scalp wound. The OHU nurses did
not evaluate the patient’s wound for three days or regularly check
the patient’s vital signs.
Medication Administration
CTC and OHU nurses generally administered prescribed medications
timely. We identified three deficiencies in our case reviews, one of which
was significant:
• In case 12, during the review period, the patient’s chronic
medication had expired and was not renewed.

61. Deficiencies occurred in cases 12, 19, 20, 50, and 51. Severe deficiencies occurred in
cases 12 and 19.

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Compliance testing showed nurses often failed to administer the
patients’ medication within the ordered time frames (MIT 13.004, 50.0%).
When our clinicians reviewed the compliance data, four of the five
samples showed no evidence the patients received their medications. In
the fifth sample, the provider did not order the medications at the time
of admission.
Clinician On-Site Inspection
COR had a 50-bed CTC assigned to medical patients and a 15-bed OHU.
Two beds were in isolation rooms in Hub A, and 26 medical beds were
in Hub B. The institution also had a 25-bed mental health crisis bed unit.
During our inspection, the CTC and OHU beds were almost full. These
specialized medical housing units are in close proximity to the TTA.
The CTC and OHU had dedicated providers who checked daily on
patients. CTC staffing included two RNs, a shift lead RN, and two LVNs
on the second and third watches. One RN was on first watch for Hub A
and one for Hub B. The shift lead and the CTC provider were responsible
for reviewing recommendations from specialty appointments and
hospital returns. Additional nursing aides assisted with patient care and
medical observation when needed.
In the OHU, an RN was assigned during the day and LVNs were assigned
in the evenings and nights. At the time of inspection, 14 beds were
occupied. Staffing consisted of one RN on second watch and one LVN on
third and first watches. In this unit, several patients needed wound care
due to chronic conditions.
We observed the CTC huddles during our on-site inspection. The shift
lead nurse demonstrated thorough knowledge of the patients’ conditions
and health needs. Other staff did not participate. Our interview revealed
that the shift lead nurse and the providers primarily managed and
coordinated patient care.
Our regional inspectors tested call lights in the CTC and OHU. All
call lights were functional with the exception of one light (MIT 13.101,
75.0%). Health care staff performed patient safety checks according to
the institution’s local operating procedure or within the required time
frames (MIT 13.102, 100%).

Recommendations
• Nursing leadership should determine the root cause of
challenges in ensuring patients who are admitted into the CTC
and OHU receive their medications timely upon admission and
implement remedial measures as appropriate.

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Compliance Testing Results
Table 17. Specialized Medical Housing
Scored Answer
Compliance Questions

Yes

No

N/A

Yes %

For OHU, CTC, and SNF: Prior to 4/2019: Did the registered nurse
complete an initial assessment of the patient on the day of admission,
or within eight hours of admission to CMF’s Hospice? Effective
4/2019: Did the registered nurse complete an initial assessment of the
patient at the time of admission? (13.001) *‡

10

0

0

100%

For CTC and SNF only (effective 4/2019, include OHU): Was a written
history and physical examination completed within the required time
frame? (13.002) *

10

0

0

100%

For OHU, CTC, SNF, and Hospice (applicable only for samples prior
to 4/2019): Did the primary care provider complete the Subjective,
Objective, Assessment, and Plan notes on the patient at the minimum
intervals required for the type of facility where the patient was
treated? (13.003) *,†

N/A

N/A

N/A

Upon the patient’s admission to specialized medical housing: Were all
medications ordered, made available, and administered to the patient
within required time frames? (13.004) *

5

5

0

50.0%

For OHU and CTC only: Do inpatient areas either have properly
working call systems in its OHU & CTC or are 30-minute patient
welfare checks performed; and do medical staff have reasonably
unimpeded access to enter patient’s cells? (13.101) *

3

1

0

75.0%

For specialized health care housing (CTC, SNF, Hospice, OHU):
Do health care staff perform patient safety checks according to
institution’s local operating procedure or within the required time
frames? (13.102) *

1

0

3

N/A

100%

Overall percentage (MIT 13): 85.0%
* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.

† CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located
in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still have
state-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of
provider follow-ups within specialized medical housing units through case reviews.

Source: The Office of the Inspector General medical inspection results.

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Inspection Period: August 2019 – January 2020

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Specialty Services
In this indicator, OIG inspectors evaluated the quality of specialty
services. The OIG clinicians focused on the institution’s ability
to provide needed specialty care. Our clinicians also examined
specialty appointment scheduling, providers’ specialty referrals,
and medical staff’s retrieval, review, and implementation of any
specialty recommendations.

Results Overview
COR provided satisfactory specialty services for their patients. The
institution generally arranged timely appointments for specialty
services, specialty follow-up, and provider follow-up. Providers referred
appropriately and nurses adequately assessed patients. We identified
some occurrences of late retrieval of specialty reports and staff not
following through with specialists’ recommendations. Our compliance
tests showed both provider review and specialty reports scanning needed
improvement. Balancing compliance testing and case reviews, we
determined a borderline adequate rating for this indicator.

71

Overall
Rating

Adequate
Case Review
Rating
Adequate
Compliance
Score
Inadequate
(71.6%)

Case Review Results
We reviewed 147 events related to this indicator, which included
76 specialty consultations and procedures. Deficiencies increased from
Cycle 5, We found 39 deficiencies, 14 of the deficiencies which were
significant.62 However, 41 percent of the deficiencies we found were in
three cases.
Access to Specialty Services
COR had good performance with access to specialty services.
In compliance testing, COR performed well in providing access
to specialty services for patients at the institution, and scored
notably in meeting policy-required time frames for routine-priority
(MIT 14.007, 100%), medium-priority (MIT 14.004, 80.0%), and highpriority (MIT 14.001, 93.3%) appointments. Case review clinicians found
deficiencies in six cases, and the following case:63
• In case 53, the provider ordered an urgent orthopedic
appointment for a hip procedure, but the patient did not receive
the appointment within the urgent time frame.
However, in our compliance testing, COR did not perform well with
access to preapproved specialty services when patients transferred

62. Deficiencies occurred in cases 8, 9, 10, 13, 14, 15, 16, 17, 18, 19, 21, 51, 52, 53, 55, and 57.
Significant deficiencies occurred in cases 8, 14, 15, 16, 19, 51, 53, and 55. Case 8 had seven
deficiencies, case 9 had four deficiencies, and case 19 had five deficiencies.
63. Deficiencies occurred in cases 15, 16, 19, 21, 51, 53, and 55. Significant deficiencies in
cases 15, 16, 19, 51, 53, and 55.

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Cycle 6 Medical Inspection Report

into the institution (MIT 14.010, 65.0%). Our clinicians did not find any
deficiencies in this area.
Provider Performance
COR providers performed well with specialty care and referred patients
to specialists appropriately. Providers followed up with patients after
they saw the specialists. Our clinicians found providers should have
arranged for specialty consultations sooner in two instances in one
case.64
We also found two instances in which providers did not always follow the
specialists’ recommendations:
• In case 8, the provider reviewed the ophthalmologist’s eye drop
recommendations, but did not follow through with the orders.
• In case 19, the provider reviewed the urologist’s
recommendations, but not follow through with the orders.
COR providers generally arranged appropriate follow-up care after
specialty consultations. Compliance testing found providers saw their
patients promptly following a specialty appointment (MIT 1.008, 81.0%).
Our case review clinicians found provider follow-up visits occurred
within the required time frames and identified no deficiencies.
Nursing Performance
We reviewed 11 cases, including 34 events in which nurses assessed
patients who returned from off-site specialty appointments. We
identified eight nursing deficiencies, four of which were significant.65
The nurses usually examined the patient, with the exception of case 8, in
which the nurse did not assess a patient who had eye surgery.
Significant deficiencies occurred when patients returned from specialty
appointments and nurses did not properly review the specialists’
recommendations. While it is ultimately the provider’s responsibility to
review the specialist’s findings and recommendations, the nurses should
communicate recommendations to the provider. In the following cases,
lapses in communication resulted in delays in care:
• In case 8, the specialist recommended a new medication for
the patient; however, the nurse did not inform the provider. As
a result, the patient received the new medication late. When
the specialist recommended changes in previous medication
orders, the nurses also did not inform the provider of these
recommendations.

64. Minor deficiencies occurred in case 9.
65. Nursing deficiencies identified in cases 8, 14, 19, 51, 52, and 55. Significant deficiencies
occurred in cases 8, 14, 19, and 55.

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California State Prison, Corcoran

73

• In case 14, the dermatologist recommended a new medication
for the patient, but the nurse did not inform the provider. The
patient received the medication two weeks late.
• In case 19, the urologist recommended frequent catheter
irrigation, kidney, ureter, and bladder X-rays, and a follow-up
with the specialist in one month for the patient. The nurses
did not inform the provider and the recommendations were
not ordered.
• In case 55, the urologist recommended a new medication and
urine culture for the patient. The nurse did not inform the
provider, resulting in a delay ordering the recommendations.
Health Information Management
COR showed room for improvement with managing specialty reports
and documents. In compliance testing, specialty documents were
scanned into the patient’s electronic health record within five calendar
days of the encounter date 66.7 percent of the time (MIT 4.002). Similarly,
in case reviews, we identified late retrieval or nonretrieval of specialty
reports in four cases and the two cases below:66
• In case 16, the orthopedic specialist injected a steroid medication
into the patient’s right hand. This specialist report was not
retrieved or scanned into the patient’s electronic health record.
• In case 19, the urologist saw the patient for a consultation.
This specialist report was retrieved and scanned six days after
the appointment.
In compliance testing, COR had a varied performance in specialty
reports retrieval and provider review of high-priority specialty
reports (MIT 14.002, 80.0%), medium-priority specialty reports
(MIT 14.005, 46.7%) and routine-priority specialty reports
(MIT 14.008, 64.3%). Our case review clinicians found COR providers
endorsed specialty reports outside the required time frames in case
55 and the following cases:
• In case 8, the provider endorsed the eye specialty report six days
after it was scanned into the patient’s electronic health record.
• In case 21, the provider endorsed the orthopedic specialty
report six days after it was scanned into the patient’s electronic
health record.
We also found when patients refused specialty appointments, staff
sometimes did not retrieve and scan the refusal forms.67
• In case 17, the patient refused an optometry appointment. COR
did not obtain a signed refusal form. A refusal form was not
scanned into the patient’s electronic health record.

66. Deficiencies occurred in cases 8, 10, 14, 16, 19, and 51. Major deficiencies occurred in
cases in 14 and 16.
67. Deficiencies occurred in cases 9, 13, 17, and 18.

Report Issued: April 2021

Office of the Inspector General, State of California

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74

Cycle 6 Medical Inspection Report

Clinician On-Site Inspection
Our clinicians met with COR’s nursing managers, the utilization
management nurse, and specialty nurses and discussed specialty referral
management and communication of specialty recommendations. Onsite specialty services included optometry, podiatry, physical therapy,
and audiology. COR utilized both telemedicine and off-site specialty
services. The telemedicine nurse reported an average of 25 specialty
appointments weekly. Some specialty services had limited access,
such as cardiology and infectious disease. Some specialty services had
challenges, such as orthopedics specialists who were located further
away in San Diego. During the preceding three months, the institution
used an e-consult referral system to quickly access specialists with a
turnaround time of less than three days. Since some specialist clinics
had closed due to COVID-19, the e-consult referral system really helped
COR with specialty access. Recently health information management
and utilization management have utilized trackers to follow up on
specialty reports. Office technicians have direct access to the electronic
medical records of the local contracted hospital, enabling access to some
specialty reports.

Recommendations
• Nursing leadership should determine the root cause of
challenges in nurses’ review of specialty reports and challenges
of informing providers of specialists’ recommendations and
implement remedial measures as appropriate.
• Medical leadership should identify the root cause in timely
provision of ordered specialty services and implement remedial
measures as appropriate.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

75

Compliance Testing Results
Table 18. Specialty Services
Scored Answer
Compliance Questions

Yes

No

Did the patient receive the high-priority specialty service within
14 calendar days of the primary care provider order or the Physician
Request for Service? (14.001) *

14

1

0

93.3%

Did the institution receive and did the primary care provider review
the high-priority specialty service consultant report within the
required time frame? (14.002) *

12

3

0

80.0%

8

2

5

80.0%

Did the patient receive the medium-priority specialty service within
15-45 calendar days of the primary care provider order or Physician
Request for Service? (14.004) *

12

3

0

80.0%

Did the institution receive and did the primary care provider review
the medium-priority specialty service consultant report within the
required time frame? (14.005) *

7

8

0

46.7%

Did the patient receive the subsequent follow-up to the mediumpriority specialty service appointment as ordered by the primary care
provider? (14.006) *

6

2

7

75.0%

Did the patient receive the routine-priority specialty service within 90
calendar days of the primary care provider order or Physician Request
for Service? (14.007) *

15

0

0

Did the institution receive and did the primary care provider review
the routine-priority specialty service consultant report within the
required time frame? (14.008) *

9

5

1

64.3%

Did the patient receive the subsequent follow-up to the routinepriority specialty service appointment as ordered by the primary care
provider? (14.009) *

7

3

5

70.0%

For endorsed patients received from another CDCR institution: If
the patient was approved for a specialty services appointment at the
sending institution, was the appointment scheduled at the receiving
institution within the required time frames? (14.010) *

13

7

0

65.0%

Did the institution deny the primary care provider’s request for
specialty services within required time frames? (14.011)

8

12

0

40.0%

Following the denial of a request for specialty services, was the
patient informed of the denial within the required time frame?
(14.012)

11

6

3

64.7%

Did the patient receive the subsequent follow-up to the high-priority
specialty service appointment as ordered by the primary care
provider? (14.003) *

N/A

Yes %

100%

Overall percentage (MIT 14): 71.6%
* The OIG clinicians considered these compliance tests along with their case review findings when
determining the quality rating for this indicator.
Source: The Office of the Inspector General medical inspection results.

Report Issued: April 2021

Office of the Inspector General, State of California

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76

Cycle 6 Medical Inspection Report

Table 19. Other Tests Related to Specialty Services

Scored Answer

Compliance Questions

Yes

No

N/A

Yes %

Specialty service follow-up appointments: Did the clinician follow-up
visits occur within required time frames? (1.008) *, †

34

8

3

81.0%

Are specialty documents scanned into the patient’s electronic health
record within five calendar days of the encounter date? (4.002) *

20

10

15

66.7%

* The OIG clinicians considered these compliance tests along with their own case review findings when
determining the quality rating for this indicator.

† CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician
follow-up visits following most specialty services. As a result, we test 1.008 only for high-priority specialty
services or when the staff orders PCP or PC RN follow-ups. The OIG continues to test the clinical
appropriateness of specialty follow-ups through its case review testing.

Source: The Office of the Inspector General medical inspection results.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

Administrative Operations
In this indicator, OIG compliance inspectors evaluated health care
administrative processes. Our inspectors examined the timeliness of
the medical grievance process and checked whether the institution
followed reporting requirements for adverse or sentinel events and
patient deaths. Inspectors checked whether the Emergency Medical
Response Review Committee (EMRRC) met and reviewed incident
packages. We evaluated and determined if the institution conducted the
required emergency response drills. Inspectors also assessed whether
the Quality Management Committee (QMC) met regularly and addressed
program performance adequately. In addition, the inspectors examined
if the institution provided training and job performance reviews for
its employees. They checked whether staff possessed current, valid
professional licenses, certifications, and credentials. The OIG rated this
indicator solely based on the compliance score, using the same scoring
thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case
review clinicians do not rate this indicator.

77

Overall
Rating

Inadequate
Case Review
Rating
(N/A)

Compliance
Score
Inadequate
(71.9%)

Because none of the tests in this indicator affected clinical patient
care directly (it is a secondary indicator), the OIG did not consider
this indicator’s rating when determining the institution’s overall
quality rating.
Nonscored Results
We obtained California Correctional Health Care Services’ (CCHCS)
Death Review Committee (DRC) reporting data and found nine
unexpected (Level 1) deaths occurred during our review period. The DRC
must complete its death review summary report within 60 calendar days
of the death. When the DRC completes the death review summary report,
it must submit the report to the institution’s CEO within seven calendar
days after completion. In our inspection, we found the DRC did not
complete any death review reports within the required time frames. The
DRC finished nine reports between 11 to 145 days late and submitted the
reports to the institution’s CEO between 5 to 152 days later (MIT 15.998).

Recommendations
• The medical and nursing leadership should ensure clinical
competency evaluations and performance appraisals are
completed timely.

Report Issued: April 2021

Office of the Inspector General, State of California

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78

Cycle 6 Medical Inspection Report

Table 20. Administrative Operations

Scored Answer
Yes

No

For health care incidents requiring root cause analysis (RCA): Did the
institution meet RCA reporting requirements? (15.001)

0

0

1

N/A

Did the institution’s Quality Management Committee (QMC) meet
monthly? (15.002)

6

0

0

100%

For Emergency Medical Response Review Committee (EMRRC)
reviewed cases: Did the EMRRC review the cases timely, and did
the incident packages the committee reviewed include the required
documents? (15.003)

9

3

0

75.0%

For institutions with licensed care facilities: Did the Local Governing
Body (LGB) or its equivalent, meet quarterly and discuss local
operating procedures and any applicable policies? (15.004)

2

2

0

50.0%

Did the institution conduct medical emergency response drills during
each watch of the most recent quarter, and did health care and
custody staff participate in those drills? (15.101)

2

1

0

66.7%

10

0

0

Did the medical staff review and submit initial inmate death reports to
the CCHCS Death Review Unit on time? (15.103)

9

1

0

90.0%

Did nurse managers ensure the clinical competency of nurses who
administer medications? (15.104)

2

8

0

20.0%

Did physician managers complete provider clinical performance
appraisals timely? (15.105)

3

6

0

33.3%

Did the providers maintain valid state medical licenses? (15.106)

14

0

0

100%

Did the staff maintain valid Cardiopulmonary Resuscitation (CPR),
Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS)
certifications? (15.107)

2

0

1

100%

Did the nurses and the pharmacist-in-charge (PIC) maintain valid
professional licenses and certifications, and did the pharmacy
maintain a valid correctional pharmacy license? (15.108)

6

0

1

100%

Did the pharmacy and the providers maintain valid Drug Enforcement
Agency (DEA) registration certificates? (15.109)

1

0

0

100%

Did nurse managers ensure their newly hired nurses received the
required onboarding and clinical competency training? (15.110)

0

1

0

0

Compliance Questions

Did the responses to medical grievances address all of the inmates’
grieved issues? (15.102)

N/A

Yes %

100%

Did the CCHCS Death Review Committee process death review
reports timely? (15.998)

This is a nonscored test. Please
refer to the discussion in this
indicator.

What was the institution’s health care staffing at the time of the OIG
medical inspection? (15.999)

This is a nonscored test. Please
refer to Table 4 for CCHCSprovided staffing information.
Overall percentage (MIT 15): 71.9%

Source: The Office of the Inspector General medical inspection results.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

79

Appendix A: Methodology
In designing the medical inspection program, the OIG met with
stakeholders to review CCHCS policies and procedures, relevant
court orders, and guidance developed by the American Correctional
Association. We also reviewed professional literature on correctional
medical care; reviewed standardized performance measures used by
the health care industry; consulted with clinical experts; and met with
stakeholders from the court, the receiver’s office, the department,
the Office of the Attorney General, and the Prison Law Office to
discuss the nature and scope of our inspection program. With input
from these stakeholders, the OIG developed a medical inspection
program that evaluates the delivery of medical care by combining
clinical case reviews of patient files, objective tests of compliance
with policies and procedures, and an analysis of outcomes for certain
population-based metrics.
We rate each of the quality indicators applicable to the institution
under inspection based on case reviews conducted by our clinicians or
compliance tests conducted by our registered nurses. Figure A–1 below
depicts the intersection of case review and compliance.

Figure A–1. Inspection Indicator Review Distribution for COR

SE
CA

Emergency
Services

Diagnostic Services

Health Care
Environment

Health Information Management
Nursing
Performance

Transfers

Preventive
Services

Medication Management
Provider
Performance

Specialized Medical Housing

Administrative
Operations

MPLIANCE
CO

REVIE
W

Access to Care

Specialty Services

Source: The Office of the Inspector General medical inspection results.

Report Issued: April 2021

Office of the Inspector General, State of California

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80

Cycle 6 Medical Inspection Report

Case Reviews
The OIG added case reviews to the Cycle 4 medical inspections at the
recommendation of its stakeholders, which continues in the Cycle 6
medical inspections. Below, Table A–1 provides important definitions
that describe this process.

Table A–1. Case Review Definitions

Case, Sample,
or Patient

Comprehensive
Case Review

Focused
Case Review

The medical care provided to one patient over a
specific period, which can comprise detailed or focused
case reviews.

A review that includes all aspects of one patient’s medical
care assessed over a six-month period. This review allows
the OIG clinicians to examine many areas of health care
delivery, such as access to care, diagnostic services, health
information management, and specialty services.

A review that focuses on one specific aspect of medical
care. This review tends to concentrate on a singular
facet of patient care, such as the sick call process or the
institution’s emergency medical response.

Event

A direct or indirect interaction between the patient and
the health care system. Examples of direct interactions
include provider encounters and nurse encounters. An
example of an indirect interaction includes a provider
reviewing a diagnostic test and placing additional orders.

Case Review
Deficiency

A medical error in procedure or in clinical judgment. Both
procedural and clinical judgment errors can result in policy
noncompliance, elevated risk of patient harm, or both.

Adverse Event

Office of the Inspector General, State of California

An event that caused harm to the patient.

Inspection Period: August 2019 – January 2020

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81

The OIG eliminates case review selection bias by sampling using a rigid
methodology. No case reviewer selects the samples he or she reviews.
Because the case reviewers are excluded from sample selection, there
is no possibility of selection bias. Instead, nonclinician analysts use a
standardized sampling methodology to select most of the case review
samples. A randomizer is used when applicable.
For most basic institutions, the OIG samples 20 comprehensive
physician review cases. For institutions with larger high‑risk
populations, 25 cases are sampled. For the California Health Care
Facility, 30 cases are sampled.

Case Review Sampling Methodology
We obtain a substantial amount of health care data from the inspected
institution and from CCHCS. Our analysts then apply filters to identify
clinically complex patients with the highest need for medical services.
These filters include patients classified by CCHCS with high medical
risk, patients requiring hospitalization or emergency medical services,
patients arriving from a county jail, patients transferring to and from
other departmental institutions, patients with uncontrolled diabetes or
uncontrolled anticoagulation levels, patients requiring specialty services
or who died or experienced a sentinel event (unexpected occurrences
resulting in high risk of, or actual, death or serious injury), patients
requiring specialized medical housing placement, patients requesting
medical care through the sick call process, and patients requiring
prenatal or postpartum care.
After applying filters, analysts follow a standardized protocol and
select samples for clinicians to review. Samples are obtained per the
case review methodology shared with stakeholders in prior cycles.
Our physician and nurse reviewers test the samples by performing
comprehensive or focused case reviews.

Case Review Testing Methodology
An OIG physician, a nurse consultant, or both review each case. As
the clinicians review medical records, they record pertinent interactions
between the patient and the health care system. We refer to these
interactions as case review events. Our clinicians also record medical
errors, which we refer to as case review deficiencies.
Deficiencies can be minor or significant, depending on the severity
of the deficiency. If a deficiency caused serious patient harm, we classify
the error as an adverse event. On the next page, Figure A–2 depicts the
scenarios that can lead to these different events.
After the clinician inspectors review all the cases, they analyze the
deficiencies, then summarize their findings in one or more of the health
care indicators in this report.

Report Issued: April 2021

Office of the Inspector General, State of California

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82

Cycle 6 Medical Inspection Report

Figure A–2. Case Review Testing
The OIG clinicians examine the chosen samples, performing either
a comprehensive case review or a focused case review, to determine
the events that occurred.

Sample = Patient = Case

Sample

No Deficiency
or Minor
Deficiency

Events
Significant
Deficiency *

A sample leading to events

Deficiencies
Not all events lead to deficiencies (medical errors); however, if errors did
occur, then the OIG clinicians determine whether any were adverse.

Sample

Significant
Deficiency *

Events

A sample leading to events that
could cause harm
Did the event
cause harm to
the patient?
* If an event (in this case,
a significant deficiency) caused harm,
the OIG clinician labels it adverse.

Yes

Adverse
Event

No

Significant
Deficiency

Source: The Office of the Inspector General medical inspection analysis.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

83

Compliance Testing
Compliance Sampling Methodology
Our analysts identify samples for both our case review inspectors and
compliance inspectors. Analysts follow a detailed selection methodology.
For most compliance questions, we use sample sizes of approximately
25 to 30. Figure A–3 below depicts the relationships and activities of
this process.

Figure A–3. Compliance Sampling Methodology

Total Patient Population

Filters

Subpopulation

Sample

Randomize

Flagging

Source: The Office of the Inspector General medical inspection analysis.

Compliance Testing Methodology
Our inspectors answer a set of predefined medical inspection tool (MIT)
questions to determine the institution’s compliance with CCHCS policies
and procedures. Our nurse inspectors assign a Yes or a No answer to each
scored question.

Report Issued: April 2021

Office of the Inspector General, State of California

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84

Cycle 6 Medical Inspection Report

OIG headquarters nurse inspectors review medical records to obtain
information, allowing them to answer most of the MIT questions. Our
regional nurses visit and inspect each institution. They interview health
care staff, observe medical processes, test the facilities and clinics, review
employee records, logs, medical grievances, death reports, and other
documents, and also obtain information regarding plant infrastructure
and local operating procedures.

Scoring Methodology
Our compliance team calculates the percentage of all Yes answers
for each of the questions applicable to a particular indicator, then
averages the scores. The OIG continues to rate these indicators based
on the average compliance score using the following descriptors:
proficient (85.0 percent or greater), adequate (between 84.9 percent and
75.0 percent), or inadequate (less than 75.0 percent).

Indicator Ratings and the Overall Medical
Quality Rating
To reach an overall quality rating, our inspectors collaborate and
examine all the inspection findings. We consider the case review and the
compliance testing results for each indicator. After considering all the
findings, our inspectors reach consensus on an overall rating for
the institution.

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

85

Appendix B: Case Review Data
Table B–1. Case Review Sample Sets
Sample Set

Total

CTC / OHU

5

Death Review / Sentinel Events

3

Diabetes

3

Emergency Services – CPR

5

Emergency Services – Non-CPR

3

High Risk

4

Hospitalization

4

Intrasystem Transfers In

3

Intrasystem Transfers Out

3

RN Sick Call
Specialty Services

21
3
57

Report Issued: April 2021

Office of the Inspector General, State of California

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86

Cycle 6 Medical Inspection Report

Table B–2. Case Review Chronic Care Diagnoses
Diagnosis

Total

Anemia

2

Arthritis/Degenerative Joint Disease

2

Asthma

6

COPD

1

Cardiovascular Disease

1

Chronic Pain

3

Cirrhosis/End-Stage Liver Disease

10

Coccidioidomycosis

2

Deep Venous Thrombosis/Pulmonary Embolism

2

Diabetes

1

Gastroesophageal Reflux Disease

5

Hepatitis C

9

Hyperlipidemia

27

Hypertension

11

Mental Health

17

Migraine Headaches

20

Seizure Disorder

1

Sleep Apnea

5

Thyroid Disease

1
129

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

87

Table B–3. Case Review Events by Program
Diagnosis
Diagnostic Services

Total
140

Emergency Care

73

Hospitalization

37

Intrasystem Transfers In

9

Intrasystem Transfers Out

9

Not Specified

1

Outpatient Care

390

Specialized Medical Housing

151

Specialty Services

147
957

Table B–4. Case Review Sample Summary

Report Issued: April 2021

MD Reviews Detailed

20

MD Reviews Focused

3

RN Reviews Detailed

15

RN Reviews Focused

41

Total Reviews

79

Total Unique Cases

57

Overlapping Reviews (MD & RN)

22

Office of the Inspector General, State of California

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88

Cycle 6 Medical Inspection Report

Appendix C: Compliance Sampling Methodology
California State Prison, Corcoran
Quality
Indicator

Sample Category

No. of
Samples Data Source

Filters

Access to Care
MIT 1.001 Chronic Care
Patients

25

Master Registry

•
•

Chronic care conditions (at least
one condition per patient — any
risk level)
Randomize

MIT 1.002 Nursing Referrals

25

OIG Q: 6.001

•

See Transfers

MITs 1.003 – 006 Nursing Sick Call
(6 per clinic)

40

MedSATS

•
•
•

Clinic (each clinic tested)
Appointment date (2 – 9 months)
Randomize

MIT 1.007 Returns From
Community
Hospital

25

OIG Q: 4.005

•

See Health Information
Management (Medical Records)
(returns from community hospital)

MIT 1.008 Specialty Services
Follow-Up

45

OIG Q: 14.001,
14.004 & 14.007

•

See Specialty Services

MIT 1.101 Availability of
Health Care
Services Request
Forms

6

OIG on-site review

•

Randomly select one housing unit
from each yard

Radiology Logs

•
•
•

Appointment date
(90 days – 9 months)
Randomize
Abnormal

Quest

•
•
•
•

Appt. date (90 days – 9 months)
Order name (CBC or CMPs only)
Randomize
Abnormal

Quest

•
•
•
•

Appt. date (90 days – 9 months)
Order name (CBC or CMPs only)
Randomize
Abnormal

InterQual

•
•
•

Appt. date (90 days – 9 months)
Service (pathology related)
Randomize

Diagnostic Services
MITs 2.001 – 003 Radiology

MITs 2.004 – 006 Laboratory

MITs 2.007 – 009 Laboratory STAT

MITs 2.010 – 012 Pathology

Office of the Inspector General, State of California

10

10

N/A at this
institution

10

Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

Quality
Indicator

Sample Category

No. of
Samples Data Source

89

Filters

Health Information Management (Medical Records)
MIT 4.001 Health Care Services
Request Forms

40

OIG Qs: 1.004

•
•

Nondictated documents
First 20 IPs for MIT 1.004

MIT 4.002 Specialty Documents

40

OIG Qs: 14.002,
14.005 & 14.008

•
•

Specialty documents
First 10 IPs for each question

MIT 4.003 Hospital Discharge
Documents

20

OIG Q: 4.005

•

Community hospital discharge
documents
First 20 IPs selected

MIT 4.004 Scanning Accuracy

24

Documents for any
tested inmate

•

Any misfiled or mislabeled
document identified during
OIG compliance review (24 or
more = No)

MIT 4.005 Returns From
Community Hospital

25

CADDIS off-site
Admissions

•
•

Date (2 – 8 months)
Most recent 6 months provided
(within date range)
Rx count
Discharge date
Randomize

•

•
•
•
Health Care Environment
MITs 5.101 – 105 Clinical Areas
MITs 5.107 – 111

15

OIG inspector
on-site review

•

Identify and inspect all on-site
clinical areas.

25

SOMS

•
•
•
•

Arrival date (3 – 9 months)
Arrived from (another
departmental facility)
Rx count
Randomize

•

R&R IP transfers with medication

Transfers
MITs 6.001 – 003 Intrasystem Transfers

MIT 6.101 Transfers Out

Report Issued: April 2021

10

OIG inspector
on-site review

Office of the Inspector General, State of California

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90

Cycle 6 Medical Inspection Report

Quality
Indicator

Sample Category

No. of
Samples Data Source

Filters

Pharmacy and Medication Management
See Access to Care
• At least one condition per
patient — any risk level
• Randomize

MIT 7.001 Chronic Care
Medication

25

OIG Q: 1.001

MIT 7.002 New Medication
Orders

25

Master Registry

•
•
•

Rx count
Randomize
Ensure no duplication of IPs
tested in MIT 7.001

MIT 7.003 Returns From
Community Hospital

25

OIG Q: 4.005

•

See Health Information
Management (Medical Records)
(returns from community hospital)

MIT 7.004 RC Arrivals —
Medication Orders

N/A at this

OIG Q: 12.001

•

See Reception Center

MIT 7.005 Intrafacility Moves

25

MAPIP transfer
data

•
•

Date of transfer (2 – 8 months)
To location/from location (yard to
yard and to/from ASU)
Remove any to/from MHCB
NA/DOT meds (and risk level)
Randomize

institution

•
•
•
MIT 7.006 En Route

10

SOMS

•
•
•
•

Date of transfer (2– 8 months)
Sending institution (another
departmental facility)
Randomize
NA/DOT meds

MITs 7.101 – 103 Medication Storage
Areas

Varies
by test

OIG inspector
on-site review

•

Identify and inspect clinical
& med line areas that store
medications

MITs 7.104 – 107 Medication
Preparation and
Administration Areas

Varies
by test

OIG inspector
on-site review

•

Identify and inspect on-site
clinical areas that prepare and
administer medications

OIG inspector
on-site review

•

Identify & inspect all on-site
pharmacies

Medication error
reports

•

All medication error reports with
Level 4 or higher
Select total of 25 medication
error reports (recent 12 months)

On-site active
medication listing

•

MITs 7.108 – 111 Pharmacy

1

MIT 7.112 Medication Error
Reporting

24

MIT 7.999 Isolation Unit KOP
Medications

17

Office of the Inspector General, State of California

•

KOP rescue inhalers &
nitroglycerin medications for IPs
housed in isolation units

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

Quality
Indicator

Sample Category

No. of
Samples Data Source

91

Filters

Prenatal and Postpartum Care
MITs 8.001 – 007 Recent Deliveries

N/A at this

OB Roster

•
•

Delivery date (2 – 12 months)
Most recent deliveries (within
date range)

Pregnant Arrivals

N/A at this

OB Roster

•
•

Arrival date (2 – 12 months)
Earliest arrivals (within date
range)

Maxor

•
•

Dispense date (past 9 months)
Time period on TB meds
(3 months or 12 weeks)
Randomize

institution

institution

Preventive Services
MITs 9.001 – 002 TB Medications

13

•
MIT 9.003 TB Evaluation,
Annual Screening

25

MIT 9.004 Influenza
Vaccinations

25

MIT 9.005 Colorectal Cancer
Screening

25

MIT 9.006 Mammogram

MIT 9.007 Pap Smear

SOMS

•
•
•

SOMS

•
•
•

SOMS

•
•
•

N/A at this

institution

N/A at this

institution

MIT 9.008 Chronic Care
Vaccinations

25

MIT 9.009 Valley Fever
(number will vary)

5

SOMS

•
•
•

SOMS

•
•
•

OIG Q: 1.001

•
•
•

Cocci transfer
status report

•
•
•
•

Report Issued: April 2021

Arrival date (at least 1 year prior
to inspection)
Birth month
Randomize
Arrival date (at least 1 year prior
to inspection)
Randomize
Filter out IPs tested in MIT 9.008
Arrival date (at least 1 year prior
to inspection)
Date of birth (51 or older)
Randomize
Arrival date (at least 2 yrs. prior
to inspection)
Date of birth (age 52 – 74)
Randomize
Arrival date (at least three yrs.
prior to inspection)
Date of birth (age 24 – 53)
Randomize
Chronic care conditions (at least
1 condition per IP — any risk level)
Randomize
Condition must require
vaccination(s)
Reports from past 2 – 8 months
Institution
Ineligibility date (60 days prior to
inspection date)
All

Office of the Inspector General, State of California

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92

Cycle 6 Medical Inspection Report

Quality
Indicator

Sample Category

No. of
Samples Data Source

Filters

Reception Center
MITs 12.001 – 008 RC

N/A at this

institution

SOMS

•
•
•

Arrival date (2 – 8 months)
Arrived from (county jail, return
from parole, etc.)
Randomize

Specialized Medical Housing
MITs 13.001 – 004 Specialized Health
Care Housing Unit

MIT 13.101 Call Buttons

10

CADDIS

•
•
•
•
•

Admit date (2 – 8 months)
Type of stay (no MH beds)
Length of stay (minimum of
5 days)
Rx count
Randomize

All

OIG inspector
on-site review

•
•

Specialized Health Care Housing
Review by location

15

MedSATS

•
•

Approval date (3 – 9 months)
Remove consult to gynecology,
consult to public health/Specialty
RN, dialysis, ECG 12-Lead (EKG),
mammogram, occupational
therapy, ophthalmology,
optometry, oral surgery, physical
therapy, or podiatry
Randomize

Specialty Services
MITs 14.001 – 003 High-Priority
Initial and Follow-Up
RFS

•
MITs 14.004 – 006 Medium-Priority
Initial and Follow-Up
RFS

15

MedSATS

•
•

•
MITs 14.007 – 009 Routine-Priority
Initial and Follow-Up
RFS

15

MedSATS

•
•

•
MIT 14.010 Specialty Services
Arrivals

MITs 14.011–012 Denials

20

20
N/A

Office of the Inspector General, State of California

MedSATS

•

Approval date (3 – 9 months)
Remove consult to gynecology,
consult to public health/Specialty
RN, dialysis, ECG 12-Lead (EKG),
mammogram, occupational
therapy, ophthalmology,
optometry, oral surgery, physical
therapy, or podiatry
Randomize
Approval date (3 – 9 months)
Remove consult to gynecology,
consult to public health/Specialty
RN, dialysis, ECG 12-Lead (EKG),
mammogram, occupational
therapy, ophthalmology,
optometry, oral surgery, physical
therapy, or podiatry
Randomize

•
•

Arrived from (other departmental
institution)
Date of transfer (3 – 9 months)
Randomize

InterQual

•
•

Review date (3 – 9 months)
Randomize

IUMC/MAR
Meeting Minutes

•
•
•

Meeting date (9 months)
Denial upheld
Randomize
Inspection Period: August 2019 – January 2020

Return to Contents

California State Prison, Corcoran

Quality
Indicator

Sample Category

No. of
Samples Data Source

93

Filters

Administrative Operations
MIT 15.001 Adverse/sentinel
events

1

Adverse/sentinel
events (ASE)
report

•

Adverse/Sentinel events
(2 – 8 months)

MIT 15.002 QMC Meetings

6

Quality
Management
Committee
meeting minutes

•

Meeting minutes (12 months)

12

EMRRC meeting
minutes

•

Monthly meeting minutes
(6 months)

MIT 15.003 EMRRC
MIT 15.004 LGB

4

LGB meeting
minutes

•

Quarterly meeting minutes
(12 months)

MIT 15.101 Medical Emergency
Response Drills

3

On-site summary
reports &
documentation for
ER drills

•
•

Most recent full quarter
Each watch

MIT 15.102 Institutional Level
Medical Grievances

10

On-site list of
grievances/closed
grievance files

•

Medical grievances closed
(6 months)

MIT 15.103 Death Reports

10

Institution-list of
deaths in prior
12 months

•
•

Most recent 10 deaths
Initial death reports

MIT 15.104 Nursing Staff
Validations

10

On-site nursing
education files

•
•
•

On duty one or more years
Nurse administers medications
Randomize

MIT 15.105 Provider Annual
Evaluation Packets

9

On-site
provider
evaluation files

•

All required performance
evaluation documents

MIT 15.106 Provider Licenses

14

Current provider
listing (at start of
inspection)

•

Review all

MIT 15.107 Medical Emergency
Response
Certifications

All

On-site
certification
tracking logs

•

All staff
◦ Providers (ACLS)
◦ Nursing (BLS/CPR)
Custody (CPR/BLS)

MIT 15.108 Nursing Staff and
Pharmacist in Charge
Professional Licenses
and Certifications

All

On-site tracking
system, logs, or
employee files

•

Report Issued: April 2021

•

All required licenses and
certifications

Office of the Inspector General, State of California

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94

Cycle 6 Medical Inspection Report

Quality
Indicator

Sample Category

No. of
Samples Data Source

Filters

Administrative Operations
MIT 15.109 Pharmacy and
Providers’ Drug
Enforcement Agency
(DEA) Registrations

All

On-site listing
of provider DEA
registration #s
& pharmacy
registration
document

•

All DEA registrations

MIT 15.110 Nursing Staff
New Employee
Orientations

All

Nursing staff
training logs

•

New employees (hired within last
12 months)

MIT 15.998 Death Review
Committee

10

OIG summary log:
deaths

•

Between 35 business days &
12 months prior
Health Care Services death
reviews

Office of the Inspector General, State of California

•

Inspection Period: August 2019 – January 2020

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California State Prison, Corcoran

95

California Correctional Health Care
Services’ Response
March 11, 2021
Roy Wesley, Inspector General
Office of the Inspector General
10111 Old Placerville Road, Suite 110
Sacramento, CA 95827
Dear Mr. Wesley:
The Office of the Receiver has reviewed the draft report of the Office of the Inspector General
(OIG) Medical Inspection Results for California State Prison, Corcoran (COR) conducted from
August 2019 to January 2020. California Correctional Health Care Services (CCHCS)
acknowledges the OIG findings.
Thank you for preparing the report. Your efforts have advanced our mutual objective of ensuring
transparency and accountability in CCHCS operations. If you have any questions or concerns,
please contact me at (916) 691‐3284.
Sincerely,

Amanda
Oltean

Digitally signed by
Amanda Oltean
Date: 2021.03.11
12:40:37 -08'00'

Amanda Oltean
Associate Director (A)
Risk Management Branch
California Correctional Health Care Services
cc: Diana Toche, D.D.S., Undersecretary, Health Care Services, CDCR
Clark Kelso, Receiver
Richard Kirkland, Chief Deputy Receiver
Katherine Tebrock, Chief Assistant Inspector General, OIG
Doreen Pagaran, R.N., Nurse Consultant Program Review, OIG
Directors, CCHCS
Roscoe Barrow, Chief Counsel, CCHCS Office of Legal Affairs
Jackie Clark, Deputy Director (A), Institution Operations, CCHCS
DeAnna Gouldy, Deputy Director (A), Policy and Risk Management Services, CCHCS
Renee Kanan, M.D., Deputy Director, Medical Services, CCHCS
Barbara Barney‐Knox, R.N., Deputy Director (A), Nursing Services, CCHCS
Annette Lambert, Deputy Director, Quality Management, CCHCS
Regional Health Care Executive, Region III, CCHCS
Regional Deputy Medical Executive, Region III, CCHCS
Regional Nursing Executive, Region III, CCHCS
Chief Executive Officer, COR
Misty Polasik, Staff Services Manager I, OIG

P.O. Box 588500
Elk Grove, CA 95758

Report Issued: April 2021

Office of the Inspector General, State of California

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96

Cycle 6 Medical Inspection Report

(This page left blank for reproduction purposes.)

Office of the Inspector General, State of California

Inspection Period: August 2019 – January 2020

Return to Contents

Cycle 6
Medical Inspection Report
for

California State Prison,
Corcoran
OFFICE of the
INSPECTOR GENERAL
Roy W. Wesley
Inspector General
Bryan B. Beyer
Chief Deputy Inspector General

STATE of CALIFORNIA
April 2021

OIG

 

 

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